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Primum Non Nocere
N C M E D I C A L B O A R D
In This Issue of the FORUM
President’s Message:
An Honor and a Privilege..............................1
From the Executive Director:
Dealing with Bureaucracy .............................1
Women Now Outnumber Men in Pharmacy....4
Desmoteric Medicine: A.K.A.,
Correctional Health Care.............................5
Post-Dated Prescriptions Not Permitted ..........6
Wayne W. VonSeggen, PA-C, Elected
President of NCMB.....................................7
Notes on Due Process .....................................8
Notice to Physician Assistants: Provisional
Approval No Longer Available....................9
NCMB Adopts Position Statement
on Laser Surgery .........................................9
Ms Erin Gough Named New Physician
Extender Coordinator..................................9
Hurricane Floyd ............................................10
Don’t Underestimate the Importance
of Chaperones ...........................................11
President’s
Message
From the
Executive
Director
Paul Saperstein Andrew W. Watry
No. 3 1999
Primum Non Nocere
NORTH CAROLINA
MEDICAL BOARD
April 15, 1859
Item Page Item Page
Before I begin my final President’s
Message, I would like to express the Board’s
deep concern about the disaster that has
struck eastern North Carolina. Nothing one
can say can assuage the pain, sorrow, and
loss felt by so many thousands of our fellow
citizens. But there is inspiration and a sense
of pride in the way the people of the whole
state have come together to lend aid of all
kinds and caring hands to those who have
suffered so much. By working together, we
can ensure that the nightmare will end and a
Carolina morning will follow.
I hope you will take a moment to read
the article, Hurricane Floyd, that our execu-tive
director, Mr Watry, has prepared to
address several questions that have come to
us since the hurricane and flooding hit. It
appears on page 10.
An Honor and a Privilege
By the time this article reaches you, my
term of office as president of the North
Carolina Medical Board will be all but over.
It is with a great amount of pride that I can
say that everything in the realm of Board
responsibilities is alive and well.
When asked to serve as the Board’s first
non-physician president approximately one
and a half years ago, I was unsure how I
would be received—not only by the Board
staff, but also by physicians, physician assis-tants,
and nurse practitioners. I quickly
found that any concerns I might have had in
this area were unfounded; my not being a
health care professional led to no opposition
to my role as president. I feel the Board has
added another dimension by allowing itself
to avoid a preconditioned belief that the
head of the Board needs to be a physician.
Serving on the Board over the last few
years, I have seen a lot of changes that have
enhanced our position as one of the top
licensing boards—not only in the state, but
in the nation. Under the leadership of our
new executive director, Mr Andrew Watry,
and his able assistant executive director, Ms
Diane Meelheim, the Board, in its structure
and operation, ranks as one of the outstand-ing
boards in the country. We have been
Dealing with
Bureaucracy
Many people derive a negative connota-tion
from the word bureaucracy. Indeed,
Webster’s gives you a choice between positive
and not so positive definitions. Yet to man-age,
we often need bureaucracy. A bureau-cracy
keeps the office open, bills for services
rendered, responds to consumers, and pro-vides
medical care. The Holy Grail is find-ing
the right balance between meeting your
organizational objectives effectively and
doing so as efficiently as possible.
The North Carolina Medical Board’s orga-nizational
objective is public protection, and
it takes bureaucracy to achieve this objective.
This often causes frustration that we would
like to minimize. In the following para-graphs,
I will offer some helpful hints that
may be useful in reducing some of these
frustrations or avoiding them entirely. These
morsels of information will appear in italics.
In dealing with any bureaucracy, the
object is to get to the end zone. If you are
trying to get to the end zone at Kenan
Stadium from Raleigh, there is a direct route
on Interstate 40 that takes from thirty to
forty-five minutes, depending on whether
you violate the speed limit. There is an infi-nite
number of indirect routes that could
take you through communities such as
Durham, Fayetteville, or Milwaukee and
would take you anywhere from 45 minutes
to several days. Dealing with a medical
licensing board is not unlike this trip to
Kenan Stadium. It could either surprise you
and be a pleasant experience or it could
totally frustrate you when you get caught in
a major traffic jam. There are ways to avoid
the major traffic jams. None of these mech-forum
continued on page 2
continued on page 4
Electronic Distribution to Be Used for
Some Forums, Bimonthly
Board Action Reports,
Immediate Action Notices.........................12
AHCPR and Other Guidelines on
Pain Available ............................................12
North Carolina Physician Demographics:
1979-1998 ................................................13
Recent Changes to PA and NP
Prescribing Rules.......................................14
Review: When Is It Futile? .............................15
Letter to the Editor: Two Questions:
Romantic Relationships, Splitting Fees ..........16
Video Tapes...................................................16
Audio Tape ....................................................17
Board Calendar..............................................17
Board Actions: 5/1999-7/1999......................18
Change of Address Form...............................24
Important Notice: Annual Registration
of Professional Corporations .....................24
DESMOTERIC MEDICINE:
A.K.A., CORRECTIONAL HEALTH CARE
See Page 5
The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum,
including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the
North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are
affiliated. Official statements, policies, positions, or reports of the Board are clearly identified.
We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form
depending on available space. A letter should include the writer’s full name, address, and telephone number.
North Carolina Medical Board
Raleigh, NC forum N C M E D I C A L B O A R D
Vol. IV, No. 3, 1999
Primum NonNocere
NORTH CAROLINA
MEDICAL BOARD
April15, 1859
Primum Non Nocere
2 NCMB Forum
Dealing with Bureaucracy
continued from page 1
we spend on the telephone. The intent is to
be efficient. For calls that branch out of this
system, we spend an average of 78 seconds
per call. In theory, one person could handle
an average of 369 of the 910 calls that come
in each work day, but that is not realistic.
There are two obvious options: doubling the
number of staff available to handle telephone
calls, or providing much more efficient
mechanisms for responding to the bulk of
calls. We are tilting toward the latter. The
idea is to strike a good balance through the
telephone system, getting callers to the end
zone as quickly as possible.
The vast majority of calls are about simple
information, such as a person’s license status,
application status, or registration status. I
will use annual registration as a simple exam-ple.
We have to print one and a half times as
many annual registration forms as we have
licensees. Fully 40% of our licensees call and
ask for a second or even third mailing of
their form. Many of these callers are angry,
implying that the Board never mailed the
registration form in the first place. I can tell
you that this accusation simply does not
make sense. Registration of a license accom-plishes
many purposes, including updating
the Board’s data on the licensee and asking
the licensee probing questions about prob-anisms
are guaranteed, but they can affect
the probability of your success. We want to
assure you that all our Board members and
staff are committed to getting you to the
end zone expeditiously. Following are but
a few suggestions that I hope you find help-ful.
The list is certainly not exhaustive and
we solicit your comments and suggestions.
Getting Licensee Information
Most of us, when we need information
from a bureaucracy, want to call that
bureaucracy immediately, talk to a human
being, and instantly get an answer. If no
one answers the telephone, we assume the
person on the other side is on a smoking
break or an extended lunch. If we get the
dreaded voice messaging system, we almost
immediately assume failure and try to find
the secret mechanisms that have been
placed in that messaging system to punch
out and get a human being.
We at the Board receive an average of
218,580 telephone calls a year, which
breaks down to 18,215 calls per month.
Yes, we have a voice messaging system that
is designed to shorten the amount of time
Paul Saperstein
President
Greensboro
Term expires
October 31, 2001
Wayne W. VonSeggen, PA-C
Vice President
Winston-Salem
Term expires
October 31, 2000
Elizabeth P. Kanof, MD
Secretary-Treasurer
Raleigh
Term expires
October 31, 1999
Kenneth H. Chambers, MD
Charlotte
Term expires
October 31, 2001
John T. Dees, MD
Cary
Term expires
October 31, 2000
John W. Foust, MD
Charlotte
Term expires
October 31, 2001
Hector H. Henry, II, MD
Concord
Term expires
October 31, 1999
Stephen M. Herring, MD
Fayetteville
Term expires
October 31, 2001
Felicia Washington Mauney, JD
Charlotte
Term expires
October 31, 2000
Walter J. Pories, MD
Greenville
Term expires
October 31, 2000
Charles E. Trado, MD
Hickory
Term expires
October 31, 1999
Martha K. Walston
Wilson
Term expires
October 31, 1999
__________
Andrew W. Watry
Executive Director
Helen Diane Meelheim
Assistant Executive Director
Bryant D. Paris, Jr
Executive Director
Emeritus
Publisher
NC Medical Board
Editor
Dale G Breaden
Editorial Assistant
Jennifer L. Deyton
__________
Mailing Address
Forum
NC Medical Board
PO Box 20007
Raleigh, NC 27619
Street Address
1201 Front Street
Raleigh, NC 27609
Telephone
(919) 326-1100
(800) 253-9653
Fax
(919) 326-1130
Web Site:
www.docboard.org/nc
E-Mail:
ncmedbrd@interpath.com
lem areas. However, it is also the principal
source of revenue for the Board. It simply
does not make sense that we would not mail
registration forms. However, as third parties
apply pressure to physicians and other
licensees to keep their licenses current, out of
an abundance of caution a lot of these regis-trants
call and ask for a second mailing of the
form. This means that, at a minimum, we
receive 12,633 calls a year just to request a
registration form, assuming that a licensee
only makes one telephone call. Most of
these calls, in 20/20 hindsight, are unneces-sary
because we mail the second form to the
same address. Of course, we need to make it
easier for licensees to get these forms should
they need them. But here are some sugges-tions
to help licensees avoid problems with
annual registration forms.
(1) Make sure your mailing address on record
with the Board is a good one. Having
your mail come into a large institution
such as a hospital or school increases
chances it won’t get to you.
(2) Don’t be unduly concerned until 15 days
before your birthday. The forms are
mailed 30 to 45 days in advance of your
birth month.
(3) If your forms are handled by others, please
advise them of the importance of your reg-istration
material, which is mailed in spe-cial
envelopes designed not to look like
junk mail.
We are devising alternate mechanisms for
responding more quickly and efficiently to
inquiries about registration and requests for
duplicate registration forms. The first order
of business has been to shift as much infor-mation
as possible to the Web. Please make
a note of our Web address, which we list here and
which we also list in every edition of the Forum:
www.docboard.org/nc. The registration data
we have put on the Web should help mini-mize
the need for a telephone call to the
Board for the same information. We have
also designed a space in the Registration sec-tion
of our site to facilitate e-mail requests
for additional registration forms. (The site
is now a rich source of information, with
details described in earlier Forum editions.
There is a place to obtain a copy of our com-plaint
form. There is a place to check on the
status of a licensee. We want to encourage
you to use our Web site as your first source
for information. If you are able to get a
quick answer to your question or inquiry, we
have been successful.) We are also providing
a voice mailbox so you can leave a message
requesting forms in the event you cannot use
the Web.
Applicants for a License
Other significant telephone queries come
from applicants. We issue about 2,337 new
continued on page 3
No. 3 1999 3
licenses a year. One thing that is common
with many of these applicants is the desire to
start work yesterday. Most applicants allow
the Board sufficient time to process an appli-cation,
never make a query, and get a license
without problems. However, I often receive
calls from applicants who ask for expedited
service, indicating that they have an immedi-ate
need to go to work but the Board is
holding them up. When I check on the sta-tus
of their application, I find that we
received it within the past 48 hours. This is
a totally unrealistic expectation. You don’t get
credentials at a major hospital or at any other
licensing board nearly that fast. Also, we
don’t expedite one applicant at the expense
of others. From a management standpoint,
one thing we see that is frustrating is the
impact these kinds of calls have on applica-tion
processing. Every minute one of our
staff people is talking on the telephone with
an applicant who is asking about the status
of his or her application is time that person
is not processing applications. This is why
we try to bracket our telephone calls about
applications between the hours of 9:00 AM
and noon. We are trying to discourage, to
the extent we can, concerned family and
friends from calling the office about applica-tions.
First, we will not discuss a confiden-tial
application with a third party. Second,
this load hinders our efficiency in turning
around applications more quickly.
We occasionally encounter applicants who
make premature employment commitments.
In some cases, these applicants actually are
put on a payroll before they are licensed. If
these applicants have a malpractice, disci-pline,
or drug and alcohol history, it takes
longer to evaluate them, and we have seen
cases where they have been terminated
because they did not have their licenses
when they thought they would. The best way
to avoid this problem is not to make premature
employment commitments. The minority of
applicants who make such commitments are
not accelerated ahead of and at the expense
of the majority of applicants who have
allowed the Board reasonable time to
process their applications.
The best advice we can give any applicant,
whether applying here or to any other licensing
Dealing with Bureaucracy
continued from page 2
1-800-253-9653
North Carolina
Medical Board
board, is to allow the Board an appropriate
amount of time, obviating the need for telephone
calls. That is the best way to get to the end zone
directly. If you have a target date to start work,
you need to have a completed application in our
office two months earlier—one month cuts it too
close. If you have significant malpractice histo-ry,
board action history, or other such problems,
you need to allow even more time. Also, we
encourage you to take advantage of alternate
mechanisms for dealing with questions about
application status. We have several improve-ments
in place or in development to help
applicants with this information. We pro-vide
a self-addressed postcard with the appli-cation
pack that you can use as a method to
confirm delivery of your application to the
Board. This is designed to minimize tele-phone
calls so we can use available staff more
efficiently to process applications. We are
looking at approaches to posting applicant
information on the Web that will protect
applicant confidentiality. We will let you
know about further developments in this
area.
Complaints
The information above deals with areas
where we are attempting to minimize tele-phone
calls in the interest of efficiency. This
clearly does not apply in the area of com-plaints.
We understand that this is a highly
sensitive area. Many people, when they call
about a complaint, are dealing with a very
sensitive issue: their health care. They do
not want to leave a telephone message. We
would encourage people to use the complaint
form from the Web site to the extent they feel
comfortable doing so. However, you will find
that the complaint component of our voice
messaging system is designed to get you to a
human being, if you need one, in short
order. We understand, for example, if you
feel you have been sexually abused, that you
do not want to leave a voice mail. This is a
very sensitive issue and you may wish to talk
to a compassionate person to relay your
information. We have a very capable com-plaint
department that is equipped to handle
this.
In the spirit of this column, which is
designed around helpful hints, we offer you
the following: try to have your facts assembled;
including the who, what, when, where, and how
of the matter. I recall one patient who sent us
a complaint that, in aggregate, was 20 pages
long. It was about a diagnostic procedure,
but there were pages and pages addressing
the nature of forgiveness, the hands of jus-tice,
and the passage of time. Now, we will
gladly receive extraneous information, but
we need as many factual investigative leads
as you can furnish. Who was the physician?
What did he or she say or do? When, where,
and how many times? Who were the wit-nesses?
Are there other patients you may
know of? Is there any supporting or corrob-orating
material, etc? We are not going to
second guess why you are filing a complaint.
We understand that these are sensitive cases
and some time may have passed since the
matter arose. We will do all in our power to
help you if we can.
Here are two things to bear in mind con-cerning
complaints. (1)The Board is a
quasi-judicial agency. It has to meet a bur-den
of proof in order to substantiate a Board
action, and there has to be a violation of law
within the Board’s jurisdiction. Not every
complaint can be successfully prosecuted.
For example, if you pay $200 to a practi-tioner
for a medical procedure and one of
your friends paid $100 for a similar proce-dure
with another doctor, there is probably
nothing we can do about that. The medical
marketplace is still part of our free market.
However, if that physician billed an insur-ance
company $200 for that same procedure
and that procedure was not performed, there
is something we can do about that. That
activity, if proven, can constitute unprofes-sional
conduct and other violations of the
law. (2)If it is taking the Board a very long
time to finally advise you as to the outcome
of the complaint, there is a good chance that
there is a legal process going on with the
licensee you are complaining about.
Complaints that are investigated and found
to be unprosecuteable are usually opened,
acknowledged to the complainant, investi-gated,
and closed with a closure letter to the
complainant within three months. If it has
been six months or a year or more since you
filed your complaint and you have received
an acknowledgment from the Board but
have not received a notification of final dis-position,
there is a good chance the Board is
actively engaged, which includes a notice to
the licensee of alleged violation, a hearing,
and final disposition. This is a legal process
and, as is the case in all other states, takes
much more time to complete.
Physicians and other health care workers
are often positioned to be aware of signifi-cant
Medical Practice Act violations. The
board has a position statement encouraging
appropriate reporting of incompetence, impair-ment,
and unethical conduct.
Emergency Action
I have described above our system for pro-cessing
contacts with the Board. We do have
mechanisms for branching out of this con-tact
system, particularly the phone messag-ing
system, in cases of emergency or
urgency: entering 0 for operator. We
encourage you to give the messaging system
continued on page 4
4 NCMB Forum
extremely pleased by the fact that Dr George
Barrett, past president of the Board, is presi-dent
elect of the national Federation of State
Medical Boards, recognizing his leadership
skills and the Board’s role in producing dis-tinguished
individuals willing and able to
serve at the highest levels. Our position has
also been enhanced by the fact that both Ms
Meelheim and Mr Watry are leading figures
in the Administrators in Medicine, the
national organization of state medical board
executives.
The Board can be extremely proud of the
quality of the work it has turned out, the
strong administrative staff it has built, the
efficiency of its service in licensing over
30,000 individuals, and the responsive
approach it has developed for dealing with
public complaints and disciplinary issues.
There have been so many changes in the
Board it would be hard to recognize them
all, but I would like to mention a few I feel
have been significant.
l The availability of Dr Jesse Roberts as
medical coordinator for the Board has
been a wonderful asset, allowing Board
members—both physician and non-physician—
to get a broader perspective
of medically-oriented complaints.
An Honor and a Privilege
continued from page 1
a chance for non-urgent inquiries; you may
actually get to the end zone much more
quickly. However, we are equipped to handle a
situation that presents an urgent risk to the pub-lic
health, safety, and welfare, such as a physi-cian
showing up for a shift in a hospital while
intoxicated. You need to punch out of our
messaging system and contact me or any of
our staff with this information so we can
address it immediately. When there is a gen-uine
risk to the public, the Board can con-duct
emergency meetings by teleconference
that can result in summary suspension of a
license, provided there is imminent risk to
the public health, safety and welfare. It takes
very little time to put all of this together.
The imminent risk standard is necessarily
high because, due to the emergency, the
Board is taking action before the licensee has
a hearing. The Board issues approximately
seven summary suspensions a year. In bro-kering
the thousands of contacts we get each
year, these matters rise to the top of the list.
General Information Requests
You may perceive this as bragging, to
which I plead guilty. However, we have one
of the best Public Affairs Departments in the
country. We have staff, at Board direction,
dedicated to making consumer information
available as readily as possible. This is done
because we recognize the importance of
health care and the importance of this infor-mation
to consumers. For example, Board
actions as a result of the disciplinary process
are actively disseminated. We do not in any
way attempt to hold public information
close to the vest; instead, we take deliberate
steps to make it easy to get. The Web page
consolidates access to this information. The
Board allocates substantial resources to this
public information effort, including the
Forum. I might add parenthetically that
these items are funded in North Carolina, as
is the case in almost all other states, entirely
with revenue from licensees, not from tax
revenue or revenue from other sources.
Conclusion
In closing, I hope this material is per-ceived
as intended, as helpful hints to having
satisfactory contacts with the Board when
attempting to get information. We all hate
automated answering systems. About once
a month, I get a message from a physician
who is furious about having to go through
an automated answering system and when I
call that physician back I wind up with an
automated answering system. It is a neces-sary
evil, but if we are using these systems
correctly, we enhance, not detract from, our
ability to respond as efficiently and as effec-tively
as we can.
Most of us, when we hear the word
bureaucracy, infer a negative connotation.
Webster’s, however, provides some options.
Bureaucracy can be either “government
characterized by specialization of functions,
adherence to fixed rules, and a hierarchy of
authority,” or “a system of administration
marked by officialism, red tape, and prolifer-ation.”
The good definition comes before
the bad one. Licensing boards, when fairly
administered, operate on fixed rules. To
allow certain applicants to accelerate their
application at the expense of others would
be chaos. To allow one licensee to be sanc-tioned
and another not for the same viola-tion
would be unfair and discriminatory.
The handling of 218,580 telephone calls,
2,337 applications for licensure, and 31,583
registration forms each year without special-ization
of function and fixed rules would be
total chaos. We aspire to help you get to the
end zone as quickly and efficiently as possi-ble,
taking full advantage of new technology.
It is a work in progress. We invite your com-ments.
u
Dealing with Bureaucracy
continued from page 3
l The increase of talented staff and the
implementation of more effective sys-tems
in the Complaint Department give
us the ability to resolve most complaints
in less than half the time it took only a
few years ago.
It is my belief that staffing enhancements
such as these are responsible for allowing the
Board to do its work on a timely basis.
We at the Board have come to recognize
that our responsibility goes beyond licensure
and discipline. To be vital, that responsibili-ty
must also involve trying to educate both
the public and the medical community as to
what the Board’s function is in the present
managed care environment and how we can
fulfill that function better. In the process, we
hope to build on the rapport we have devel-oped
with the health care professionals and
the public we serve to ensure that the basic
trust that has always been and is so essential
a part of the patient/physician relationship is
never broken or forgotten as changes evolve
in the delivery of health care. I consider
North Carolina to have the best community
of physicians, physician assistants, and nurse
practitioners in the country, and nothing
should be allowed to impinge on their abili-ty
to provide appropriate medical care to the
people of this state.
I have considered it an honor and a privi-lege
to be president of the North Carolina
Medical Board. I have appreciated the
opportunity afforded me by the other mem-bers
of the Board. I know that the next pres-ident,
Wayne VonSeggen, PA-C, of
Winston-Salem, will do an excellent job and
serve the Board with professionalism, dis-tinction,
and honor. u
Women Now
Outnumber Men
in Pharmacy
According to the April issue of the
North Carolina Board of Pharmacy
News, for the first time in North
Carolina’s history, as of January 1999,
the majority of active pharmacists are
women. Board statistics reveal that,
both full-time and part-time, there are
3,227 female pharmacists active in this
state and 3,223 male. These figures
reflect recent pharmacy school gradua-tion
statistics, which in North Carolina
indicate that women are about 70 per-cent
of the graduates.
No. 3 1999 5
continued on page 6
At mid-year
1997, more than 1.7
million people, or
one of every 155
U.S. residents, were
in either jail or
prison. At year-end
1997, one of every
117 males and one of
every 1,852 females
were sentenced pris-oners
under state or
federal criminal jurisdiction.1 Fifteen million
arrests are made annually2 and over ten mil-lion
individuals are released from detention
each year. Approximately two-thirds of
incarcerated individuals are in state and fed-eral
facilities, and the remaining third are in
local, generally short-term stay jails. The
incarcerated popula-tion
cannot and must
not be considered a
small, separate popu-lation
with little rele-vance
to the outside
community.
When offenders
are sentenced to
prison, the state
becomes responsible
for providing them
health care. Desmoteric medicine is the prac-tice
of medicine where the patient popula-tion
is incarcerated or in “bonds.” The term
“desmoteric” originates in the Greek root
desmos, meaning band, bond, or ligament.
Historical Trends
In the 1950s and 60s, health care needs of
the incarcerated were primarily acute injuries
and illnesses consistent with health care
needs of a younger, essentially healthy popu-lation.
Closure of many public mental insti-tutions
in the 1970s led to the incarceration
of many mentally ill for charges stemming
from illness-induced behaviors. In addition,
the National Drug Control Strategy,
announced in 1989, called for mandatory
minimum sentences for drug crimes. By
1995, the impact of the strategy had dra-matically
altered the composition of the
prison inmate population: the number of
inmates in state prisons for drug offenses as
their most serious crime had increased 478%
over the 8.6% reported in 19853. More
recently, mandatory sentencing and longer
prison sentences have contributed to the
increasing trend of older inmates with
chronic diseases: hypertension, coronary
artery disease, chronic obstructive pul-monary
disease, diabetes, hepatitis, HIV, and
others.
The impact of these trends in the North
Carolina prison system has caused our state
prison population to nearly double in 10
years; from approximately 17,000 in 1989
to nearly 33,000 in 1999. Chronic medical
conditions, mental disorders, disease states
associated with drug use, and constant
advances in the treatment of HIV and new
therapies for hepatitis C have created signif-icant
challenges in the provision of health
care to this unique population.
Constitutional and Statutory
Obligations
The Health Services Section of the North
Carolina Department of Correction (DOC)
is mandated to provide inmate medical ser-vices
that meet community standards. Our
constitutional obligation, grounded in the
Eighth Amendment, and the statutory
requirement, GS 135-40.7(5), are best
described in one of the landmark court deci-sions
impacting correctional health care,
Estelle vs Gambel: “...deliberate indifference
to the serious medical needs of prisoners
constitutes the unnecessary and wanton
infliction of pain” in violation of the 8th
Amendment. This requirement and the
North Carolina statutory requirement (GS
135-40.7(5)) charge DOC Health Services
to provide inmates access to quality care pro-vided
by competent health care professionals.
NC DOC Health Services Mission
The North Carolina DOC Health Services
mission is to meet our constitutional and
statutory obligation in a fiscally responsible
manner by:
l viewing correctional facilities as public
health stations that significantly impact
the health status of the larger community;
l managing the care in order to improve
the health status of the inmate and non-inmate
population in order to get best
value for the total tax dollars spent;
l continually asking five questions:
Does the care meet community
standards?
Is the care good medicine?
Is the care appropriate for
the inmate?
Is the care provided good for
the public health?
Have we managed the care in a way
that does not sacrifice quality
and community standards?
Primary Care Driven System
Currently, inmate health care includes
physical, dental, and mental health services
that inmates receive on admission to the
Department of Corrections and throughout
their incarceration. When they enter the sys-tem
through one of the Department’s pro-cessing
centers, inmates receive a number of
health care examinations conducted by
health services staff. Inmates receive a phys-ical
examination, including any needed labo-ratory
tests and X-rays. They receive a visu-al
dental exam and, when determined neces-sary
by a dentist, X-rays and treatment to
correct existing problems. Additionally,
inmates receive a mental health screening,
which includes testing and an interview by
mental health staff to determine their current
psychological functioning level. As a result
of these examinations, health services staff
assigns each inmate a medical classification
status that indicates his or her physical and
mental capability for
institutional and
work assignments.
Inmates who have
been identified as
having a chronic
medical condition,
such as diabetes, asth-ma,
hypertension,
seizures, and/or HIV,
are scheduled for rou-tine
follow-up visits
at intervals not to exceed 90 days once they
reach their assigned institutions.
At each of our major correctional institu-tions,
on-site health care staff provides pri-mary
health care services to inmates. Health
care staff are available or on call 24 hours per
day. Inmates requiring consultations with
specialists or tertiary care not readily avail-able
within the Department are transported
to community facilities for treatment. When
necessary, emergency care is provided by the
closest hospital emergency room.
As in the rest of society, the delivery of
health services in prisons is generally based
on a patient requesting services via the “sick
call” process, describing symptoms, and fol-lowing
the doctor’s instructions. Clearly,
many patients in the “free world” seek health
services in an attempt to obtain secondary
Desmoteric Medicine: A.K.A., Correctional Health Care
Barbara L. Pohlman, MD, MPH
Director, Health Services/Medical Director, Health Services Section
North Carolina Department of Correction’s Division of Prisons
Dr Pohlman
“The incarcerat-ed
population
cannot and must
not be considered
a small, separate
population with
little relevance to
the outside com-munity.”
“ ‘...deliberate
indifference to
the serious med-ical
needs of pris-oners
constitutes
the unnecessary
and wanton
infliction of
pain’ ”
6 NCMB Forum
Desmoteric Medicine
continued from page 5
gain (ie, excused absences from work, dis-ability
benefits, etc). A recent study by the
Florida Office of Program Policy Analysis
and Government Accountability highlighted
how secondary gain is magnified in the
incarcerated population: “In prison, health
services is a primary means by which inmates
can achieve secondary gains, such as avoid-ing
work, relieving boredom, talking to
nurses and other medical staff, or being
transported out of the institution to a com-munity
hospital or another institution.
Inmates may describe false or exaggerated
symptoms in an attempt to achieve sec-ondary
gain.”4 The examples cited in the
Florida study are not uncommon in North
Carolina.
l An inmate who complains of foot pain
may be accurately describing a medical
problem or may simply be trying to
obtain a medical exemption that would
allow him to wear softer shoes than the
Department’s regulation footwear.
l An inmate who visits sick call complain-ing
of lower back pain may be feigning
symptoms in hopes of obtaining an
assignment to a lower rather than an
upper bunk.
l An inmate who declares a mental health
emergency, such as self-injurious behav-ior,
may be seeking to be moved to a
crisis stabilization unit or to a different
institution for some other gain, such as
location, interaction with staff or other
inmates, etc.
Trained nursing staff triage patients for
sick call, assess and treat patients according
to written nursing protocols, and refer
patients to physician extenders and physi-cians
as appropriate. The process is similar
to that of a typical primary care practice.
The North Carolina Correctional
Health Care System
In the last few years, our system has trans-formed
from a provider of prison health ser-vices
to a health care system that provides
services in the correctional environment.
Today, we function as a managed care orga-nization
with expenditures of approximately
$103M. The Health Services Division of
the NC Department of Corrections is a man-aged
care organization with:
l approximately 33,000 covered lives,
l 20,000+ new admissions per year,
l 3 inpatient facilities,
l 84 ambulatory/primary care centers,
l aggressive utilization management,
l aggressive claims management.
Despite population increases and a variety
of factors that tend to increase the cost of
inmate health care, inmate health care costs
in North Carolina have grown at a slower
rate than overall medical costs and at a slow-er
rate than medical care inflation. The
Department’s cost containment efforts have
been effective in reducing costs and include:
l establishing an inmate co-payment sys-tem,
whereby inmates pay $3 for
inmate-initiated, non-emergency visits
or $5 for an inmate-declared medical
emergency;
l establishing a utilization review system
that requires pre-certification and
authorization for off-site specialty con-sults,
outpatient and inpatient services;
l establishing managed care contracts
with community hospitals and special-ists;
l utilizing telemedicine to provide a video
link between inmates and medical spe-cialists;
l monitoring claims from outside
providers for overcharges, incorrect
coding, and contractual reimbursement
compliance issues.
Career Opportunities in Desmoteric
Medicine
Good medicine is good medicine, wherev-er
it is practiced. In a security/custody envi-ronment,
correctional officers have an
important role in the delivery of healthcare:
control of patient flow, transportation of
patients, records,
observations on
behavior, etc. In
addition, the
correctional offi-cer
often has
knowledge of
specific inmate
behaviors and
activities that are
invaluable to the
licensed health
care profession-al,
ie, eating patterns and preferences, med-ication
adherence issues, recreational activi-ties,
etc. Desmoteric medicine is a true
multi-disciplinary team effort that provides
appropriate, medically necessary care for our
patients.
Work with inmate patients in this special
environment is challenging, interesting, and
provides clinical experiences that are not
often encountered in the “free world.” For
the physician or physician extender with the
interest and aptitude to work collaboratively
and cooperatively in a team environment on
challenging clinical issues, desmoteric medi-cine
offers a challenging and satisfying career
opportunity.
“In the last few
years, our system has
transformed from a
provider of prison
health services to a
health care system
that provides services
in the correctional
environment.”
————————————
Notes
1. U.S. Department of Justice. Bureau of Justice
Statistics Bulletin: Prisoners in 1997, August 1998.
2. CDC. Assessment of Sexually Transmitted
Diseases Services in City and County Jails—
United States, 1997. MMWR, 1997, 47:429-31.
3. Bureau of Justice Statistics, Correctional
Populations in the United States, 1996. U.S.
Department of Justice, Office of Justice Programs.
Washington, DC.
4. The Florida Legislature, Office of Program
Policy Analysis and Government Accountability.
Review of Inmate Health Services Within the
Department of Corrections. Report No 96-2. u
Post-Dated
Prescriptions Not
Permitted
Donald Pittman
Field Supervisor, NCMB Investigative
Department
From time to time, Board investiga-tors
discover prescriptions issued for
controlled substances that have been
“post-dated.” The authorizing physi-cian,
for various reasons, will issue two
or more prescriptions to a single patient
for the same medication, record on one
the date the prescription was written
and on the other(s) the date(s) in the
future. According to the Code of
Federal Regulations, Part 1306.05(a),
all prescriptions for controlled sub-stances
shall be dated as of, and signed
on, the day when issued and shall bear
the full name and address of the
patient; the drug name, strength,
dosage form, quantity prescribed, and
directions for use; and the name,
address, and registration number of the
practitioner. A prescription for a con-trolled
substance with a recorded date
other than the day it was issued would
not be in compliance with this federal
regulation.
Whatever the reason a physician may
have for issuing multiple prescriptions
for the same medication to one patient
during a single office visit, there is an
acceptable approach to accomplishing
this. A physician may issue two or
more prescriptions for the same med-ication
on the same day by dating them
all the day they are issued and writing
“do not fill until (future date[s] that
medication may be dispensed)” on the
one(s) to be filled at a later time.
No. 3 1999 7
Wayne W. VonSeggen, PA-C, of Winston-Salem,
Elected President of North
Carolina Medical Board: First Physician
Assistant to Hold The Post
At its regular meeting in July, the North
Carolina Medical Board elected its officers
for the next year. They will take office on
November 1, 1999, and serve until October
31, 2000.
Wayne W. VonSeggen, PA-C,
New NCMB President
Wayne W. VonSeggen, PA-C, of
Winston-Salem, will
assume the post
of president of
the North Carolina
Medical Board on
November 1, suc-ceeding
Mr Paul
Saperstein, of Greens-boro,
in that posi-tion.
Mr VonSeggen
is the first physician
assistant to be chosen
president of the Board. He has served as
vice president of the Board over the past
year.
Mr VonSeggen, a native of Iowa, has been
a physician assistant for over 22 years and
currently works with Dr George Franck at
the Employee Health Center at Wake Forest
University Baptist Medical Center in
Winston-Salem. He received his BA degree
in chemistry and zoology from Olivet
Nazarene University in Illinois, with gradu-ate
work in anatomy at the University of
Iowa, and completed the Physician Assistant
Program at Bowman Gray School of
Medicine of Wake Forest University. He is a
fellow member of the American Academy of
Physician Assistants, a charter member of
the North Carolina Academy of Physician
Assistants, and an associate member of the
North Carolina Medical Society, participat-ing
with the Bioethics Committee.
Mr VonSeggen has served as president of
the North Carolina Academy of Physician
Assistants, has coauthored the results of
three state-wide surveys of the PA profes-sion,
and plays an active role in several pro-fessional
organizations. He was named to
the Board in 1994 and has acted as chair of
the PA Committee, nominating members of
the PA Advisory Committee to the Board.
He has been a member of several other key
Board committees, including the Licensing,
Investigations, EMS, and Scope of Practice
Committees.
Mr VonSeggen
Elizabeth P. Kanof, MD, Vice
President
Also on November 1, Elizabeth P.
Kanof, MD, of
Raleigh, will be-come
vice president
of the North
Carolina Medical
Board, replacing
Mr VonSeggen. Dr
Kanof was appoint-ed
to the Board in
1996 and served as
secretary-treasurer
over the past year.
Dr Kanof, a native of New York, received
her BA from Mount Holyoke College and
her MD from New York University. She did
an internship at Kings County Hospital
Center and residencies in dermatology at
New York University-Bellevue Medical
Center and Duke University Medical Center.
She is a fellow of the American Academy of
Dermatology and a diplomate of the
American Board of Dermatology. She holds
appointments as assistant clinical professor
of dermatology at the Duke University
School of Medicine and as adjunct clinical
professor of dermatology at the University
of North Carolina School of Medicine.
Very active in organized medicine, Dr
Kanof served as president of the Wake
County Medical Society in 1984 and of the
North Carolina Medical Society in 1994.
She has served on or chaired numerous
Medical Society committees and currently
serves as a Medical Society delegate to the
American Medical Association. Over the
years, she has also been a participant in a
wide range of community and charitable
groups.
She has published several articles and, in
1996, was coauthor of “Overcoming
Barriers to Physician Involvement in
Identifying and Referring Victims of
Domestic Violence,” published in the
Annals of Emergency Medicine.
Dr Kanof has served on the Board’s
Malpractice, Physician Assistant, Physicians
Health Program, and Liaison Committees,
and has been chair of its Complaints, Scope
of Practice, and Alternative Medicine
Committees.
Dr Kanof
Walter J. Pories, MD, Secretary-
Treasurer
Walter J. Pories, MD, of Greenville, will
take office as the
Board’s new secre-tary-
treasurer on
November 1, replac-ing
Dr Kanof. A
native of Germany,
Dr Pories is profes-sor
of surgery
and biochemistry at
the East Carolina
University School of
Medicine. He is also
a clinical professor of surgery at the
Uniformed Services University of Health
Sciences. He received his BA at Wesleyan
University, Middletown, Connecticut, and
his MD with honors from the University of
Rochester School of Medicine and Dentistry.
His postgraduate study included an intern-ship
at Strong Memorial Hospital of the
University of Rochester; a part-time fellow-ship
at the Centre du Cancer of the
Universite de Nancy, France; a graduate
research fellowship in biochemistry at the
University of Rochester; and a residency in
general and thoracic surgery at Strong
Memorial Hospital. He is certified by the
American Board of Surgery and the
American Board of Thoracic Surgery. He
was appointed to the North Carolina
Medical Board in 1997.
Frequently honored for his work as a sur-geon
and teacher, Dr Pories is a past gover-nor
of the American College of Surgeons
and has served as president of the North
Carolina Chapter of the American College of
Surgeons, the North Carolina Surgical
Association, the Eastern Carolina Health
Organization, Hospice of Greenville, and
the Association of Program Directors in
Surgery. Active on a large number of pro-fessional
boards and committees, he is also
the author/coauthor of 47 book chapters, 7
books, and over 250 medical articles dealing
primarily with the metabolism of trace ele-ments,
diabetes, and surgical education. He
has also been involved in the making of four
educational films.
Dr Pories is a retired colonel of the U.S.
Army Reserves. He has published over 50
cartoons and is a talented artist. u
Dr Pories
8 NCMB Forum
continued on page 9
Why Give Due Process?
Deciding whether to deny an applicant a
license and considering whether to take one
away are among the most difficult and
wrenching decisions the North Carolina
Medical Board must make. The Board nei-ther
relishes these duties nor shrinks from
them. Usually, a person appearing before
the Board has invested a
lifetime to reach profes-sional
goals. Society,
likewise, has a consider-able
stake: its own
investment in the per-son’s
education and
training and its need for
protection from the
occasional unscrupulous, incompetent, or
impaired medical professional. Because so
much is at stake, emotions tend to run high.
To help ensure that these decisions are
carefully and fairly made, the Board must
follow certain law and rules, commonly
referred to as “due process” after the lan-guage
of the Fifth Amendment to the U.S.
Constitution, which states that no one shall
“be deprived of life, liberty, or property,
without due process of law.” The North
Carolina Constitution, in its “law of the
land” clause contains a very similar idea.
Basically, the concept is that a state (acting in
this case through a medical board) must use
due process before depriving a person of a
property right (in this case a license or other
approval to practice). The question, then, is,
What process is due a person in these cir-cumstances?
What Process Is Due?
It surprises some that the Board’s power is
not absolute on such matters. The constitu-tions
establish a minimum, the fundamentals
of which, generally speaking, include having
notice that the matter is being considered
and an opportunity to be heard. Statutes
passed by the General Assembly, and to
some extent by Congress, provide more,
governing the reasons the Board may act,
the procedures it must follow, and the
actions it may take. While few Board deci-sions
are ever disturbed, its actions are sub-ject
to review by the courts.
On What May the Board Act?
Statutes (and rules for physician assistants,
nurse practitioners, and emergency medical
technicians) set forth the reasons the Board
may deny a license or take one away. About
20 reasons are given. Many are fairly obvi-ous:
unethical or unprofessional conduct,
incompetence, and being impaired. Others
are less so, for example, not paying child
support. Some of these are written in broad
and general terms, allowing the Board to
enforce professional standards within the
common understanding of those in practice.
Others are fairly specific, for example, failure
to register. Only the one requiring continu-ing
medical education explicitly authorizes
the Board to make rules outlining its con-tours.
In sum, the Board has broad power
to act, but unless one of these reasons in the
statutes or rules applies, the Board’s hands
are tied. As an example, without more to act
on, conviction of a misdemeanor is not nec-essarily
grounds for discipline.
What Procedures Must the Board Use?
In its investigations
Statutes set forth the procedures the
Board must use. It is given broad but not
unlimited powers in investigating its cases.
For example, the Board can obtain patient
records without obtaining a court order (as
is usually required in court cases), but it does
not have the power to search without con-sent
(as in a search warrant) nor does it make
arrests.
In its hearings
Proceedings before the Board are much
like civil cases in court. Statutes govern how
the Board begins a case, who will hear the
case, and where the case will be heard.
Statutes govern the discovery process by
which information is exchanged in the case,
what portions of the proceeding and docu-ments
are public, and what evidence is
admissible. Statutes give the Board’s oppo-nents
rights to appear personally and with a
lawyer, to cross examine witnesses, to pre-sent
evidence, to subpoena witnesses, and to
make arguments. Statutes give the presiding
officer judge-like powers and require the
Board to act somewhat like a jury. Statutes
govern the right to appeal a Board decision,
which is fairly similar to appeals in civil
cases, going through the courts to ensure the
Board has acted lawfully, that its decisions
are supported by the evidence, and that it
has not acted arbitrarily or capriciously.
What May the Board Do?
Statutes govern the actions the Board may
take, giving it the power to deny an applica-tion,
annul, revoke, suspend, or limit a
license. Under limited circumstances, the
Board may order restitution. It may also
stay its actions or restore a license on condi-tions.
In emergencies, the Board may sus-pend
or summarily suspend a license pend-ing
the outcome of a case, but it must
promptly begin and decide the case after
doing so. It does not have the authority to
do other things, such as fine or imprison.
Can the Process Be Abbreviated?
Sometimes hearings before the Board are
conducted elaborately, using all the proce-dures
set out above in all their detail.
Usually, considerable effort is applied to nar-rowing
the issues to those truly in dispute,
and, with the consent of the Board and the
affected person, the unnecessary procedures
can be discarded. Put another way, the
process is designed not only for fairness but
also for efficiency.
Consent Orders
At any point in the process, from before
charges are brought to after the hearing is
held, the Board and the affected person can
agree to a resolution of the matter. Public
policy in North Carolina encourages the
Board, though the law does not require it, to
attempt resolution of cases through informal
means. When an accord can be reached, the
law expressly permits an agreed disposition
of the matter.
The usual mechanism is a Consent Order.
Consent Orders are both orders of the Board
and agreements between the Board and the
affected person. Consent Orders typically
begin by identifying
the affected person
and setting forth the
areas of concern to
be addressed. Next,
Consent Orders
recite the obligations
of the Board and the
affected person, for
example, the person’s
license status and the
conditions on which the continuation of that
status depend. Consent Orders contain an
enforcement mechanism, usually that a fail-ure
to abide by the Consent Order will con-stitute
grounds for the Board to act, even if
the law would not otherwise give the Board
such power.
How Much of This Is Public?
By statute, the Board’s licensing and
investigative information is not public,
unless and until it is used in a case before the
Board. Also by statute, once the Board
Notes on Due Process
James A. Wilson, JD
Director, NCMB Legal Department
“No one shall
‘be deprived of
life, liberty, or
property, with-out
due process
of law.’ ”
“Because the
Board’s decisions
can end a career,
it is important
they be made
carefully and
deliberately.”
No. 3 1999 9
Notes on Due Process
continued from page 8
NCMB Adopts
Position Statement on
Laser Surgery
At its meeting in July, the North Carolina
Medical Board adopted a positon statement
on laser surgery. It appears below.
The principles of professionalism and per-formance
expressed in the position state-ments
of the North Carolina Medical Board
apply to all persons licensed and/or
approved by the Board to render medical
care at any level. (The words “physician”
and “doctor” as used in the position state-ments
of the Board refer to persons who are
MDs or DOs licensed to practice medicine
and surgery in North Carolina.)
LASER SURGERY
It is the position of the North Carolina
Medical Board that the revision, destruction,
incision, or other structural alteration of
human tissue using laser technology is
surgery.* Laser surgery should be per-formed
only by individuals licensed to prac-tice
medicine and surgery or by those cate-gories
of practitioners currently licensed by
this state to perform surgical services.
Licensees should use only devices
approved by the U.S. Food and Drug
Administration unless functioning under
protocols approved by institutional review
boards. As with all new procedures, it is the
licensee’s responsibility to obtain adequate
training and to make documentation of this
training available to the North Carolina
Medical Board on request.
Lasers are employed in certain hair-removal
procedures, as are various devices
that (1) manipulate and/or pulse light caus-ing
it to penetrate human tissue and (2) are
classified as “prescription” by the U.S. Food
and Drug Administration. Hair-removal
procedures using such technologies should
be performed only by a physician or by a
licensed practitioner with appropriate med-ical
training functioning under the supervi-sion,
preferably on-site, of a physician who
bears responsibility for those procedures.
*Definition of surgery as adopted by the NCMB,
November 1998:
Surgery, which involves the revision, destruc-tion,
incision, or structural alteration of
human tissue performed using a variety of
methods and instruments, is a discipline that
includes the operative and non-operative
care of individuals in need of such interven-tion,
and demands pre-operative assessment,
judgment, technical skills, post-operative
management, and follow up. u
(Adopted July 1999)
begins a case, much becomes public. The
Notice of Charges is public, as is any
response to it. The hearings themselves are
open to the public, and the things admitted
into evidence and the transcripts of testimo-ny
are public. Though the Board’s delibera-tions
are closed, its final written decisions are
public. Appeals of Board decisions are pub-lic.
Consent Orders are public. However,
by statute, the Board will protect the identi-ty
of patients who do not consent otherwise.
Conclusion
Contrary, perhaps, to the impression of
some, the Board is not set at large to “make
things right.” It can act only on the grounds
set forth in the law, using only the proce-dures
and taking only the actions established
by law.
Obviously, no system can ensure perfect
decisions, and because the Board’s decisions
can end a career, it is important they be made
carefully and deliberately. The procedures
outlined here are designed to guide the
Board to fair and just consideration of each
case it addresses.
Notice to Physician
Assistants:
Provisional
Approval No
Longer Available
The North Carolina Medical Board
wants you to be aware that provisional
approval is no longer available for
physician assistants. (Provisional
approval is not to be confused with a
temporary license, which is the type of
license a PA receives before taking or
passing the examination of the
NCCPA.) Temporary and full license
numbers will be assigned once each
month during the regularly scheduled
meetings of the Board. This approach
is required because there is no provi-sion
in the statutes of North Carolina
for staff approval of a license applica-tion;
it must be voted on by the Board.
An applicant can expect to get her or
his license number in writing within
seven business days following the last
day of the Board meeting at which the
application is approved. Application
deadlines are printed in each issue of
the Forum.
Ms Gough
Ms Erin Gough
Named New
Physician Extender
Coordinator
Ms Erin Gough is the new
Physician Extender Coordinator for
the Licensing Department of the
North Carolina Medical Board. She
succeeds Ms Terresa Wrenn.
Ms Gough is primarily responsible
for processing physician assistant
applications and intent to practice
applications. Her duties include
preparing PA materials for review by
the Board and staffing Nurse
Practitioner, Physician Assistant, and
Midwifery Committee meetings. She
also assigns PA license numbers and is
authorized to make written and verbal
verifications of PA licenses and NP
practitioner approvals.
She is available to answer telephone
inquiries regarding application
requests, application status, verifica-tions,
and rules applicable to PAs and
NPs on any weekday from 2:30 to
5:00 PM. She may be reached at
(800) 253-9653, extension 233, or
(919) 326-1100, extension 233.
Mr James Campbell continues to
handle NP applications (initial and
subsequent). Questions about these
may be directed to him on any week-day
from 2:30 to 5:00 PM. He may
be reached at (800) 253-9653, exten-sion
250, or (919) 326-1100, exten-sion
250.
The NCMB’s Web site features a
useful description of the Licensing
Department and now offers the PA
Intent To Practice Form. The rules
and the Medical Practice Act may also
be downloaded from the site. The
address is www.docboard.org/nc. u
10 NCMB Forum
Hurricane Floyd and its accompanying
deluge of rain presented a disaster of
unprecedented proportions for North
Carolina—particularly the eastern portion
of our state. The problems its aftermath
presents our licensing system are pale by
comparison with the misery and suffering
of thousands of our citizens. However, it
did affect our licensing system and we
have had serious questions about licensing
issues. In an effort to be helpful, we offer
the following suggestions that may be of
benefit to those adversely affected.
Medical Records
As you know, the Board has a position
statement on medical records. This posi-tion
statement, along with the rules and
laws governing the practice of medicine,
can be found at our Web site at
www.docboard.org/nc. Several physicians
had their offices flooded by Floyd and did
not have enough time to salvage their
medical records, which are now so much
mush.
We have received questions about what
would happen if, in the future, one of
these physicians was called on to produce
a patient chart that had been destroyed by
flood waters? In that regard, we want you
to know that one of the reasons this state
and all other states have medical boards is
to provide a group of reasonable, respon-sible
board members, fellow citizens, to
apply prudent judgement on public pro-tection
issues. The North Carolina
Medical Board is among the most reason-able
and prudent you will find anywhere
in the country. You can read between the
lines of the Board’s position statements
the public policies that are the foundation
for those statements. The Board is
attempting to ensure that there is continu-ity
of patient care, that patients have
access to their medical records, and that
medical records are appropriately docu-mented
so they are useful instruments in
managing patient care. That being said, if
an issue presents itself one, two, or five
years from now where a medical record is
requested to resolve a patient complaint or
similar issue, you can expect the Board to
be reasonable if the physician’s office or
record storage area was ravaged by the
floods accompanying Floyd in September
1999. It may simply be impossible for
that physician to produce a good medical
record because of the flood damage.
We have suggested to those who have
asked that they should apply the same prin-ciples
to rebuilding badly damaged or
destroyed records as they would to triaging
patients. That is, they should identify the
patients with the most urgent needs, includ-ing
those requiring routine prescriptions,
and try to rebuild those records first based
on memory and any other sources available.
We have also suggested placing a note in
each patient’s file stating that certain records
were not recoverable due to flood damage
and the basis on which a reasonable, good
faith effort was made to restore such records.
This document itself will serve as part of the
medical record to explain the absence of crit-ical
documentation. (We recognize that, in
some instances, it may not be possible or
reasonable to attempt the rebuilding of a
particular record.)
In summary, a licensee can expect the
Board to be reasonable in future issues when
original and complete patient records cannot
be produced as a result of Floyd’s devasta-tion.
The Board simply expects licensees to
make reasonable efforts to restore those
records, where appropriate, consistent with
the public policy that governs the Board’s
actions.
Volunteerism
Balancing the negative effects of this
tragedy are the significant volunteer efforts
to help people recover. There is considerable
volunteerism occurring in the medical com-munity.
We have received the inevitable
licensing question as a result. This state, as
is the case in most other states, has an emer-gency
plan whereby the Governor can take
emergency action to relax licensing statutes
where appropriate. Exercising this authority
in the case of Floyd was not necessary.
Licensing statutes exist for a good reason:
public protection. In a disaster such as North
Carolina has suffered, the public needs to be
protected from fleecing by price-gouging,
shoddy contractors, and others who might
take advantage of such a situation. Medicine
is no exception. There are over 5,000 physi-cians
disciplined in this country each year for
rather significant violations of public trust.
There are many thousands more people in
this country who were trained as physicians
but who have not demonstrated the mini-mum
competencies required by the licensing
system, such as passing a licensing exam,
completing appropriate post-graduate train-ing,
and passing credential checks involving
criminal history, action in other states, mal-practice
history, etc.
There is significant volunteerism by
appropriately licensed and credentialed
physicians and, frankly, no need to com-pound
this disaster by exposing our citi-zens
to medical personnel who have not
been appropriately credentialed. The
North Carolina Medical Society has risen
to the task of coordinating volunteerism
for this critical situation from the large
pool of physicians who hold a North
Carolina license.
Any physician who would like to put
his or her name on a list of volunteers to
help in future emergencies should write or
telephone the North Carolina Medical
Society: 222 North Person Street,
Raleigh, NC 27601; (919) 833-3836.
Immunization
There is an increased need for immu-nizations
due to the ravages of Floyd.
Fortunately, this state has an effective
approach to making immunizations avail-able
to the public at times like this. They
are available through the health depart-ments
and from a variety of authorized
health care providers.
Clearly, immunizations should be given
only by those qualified and authorized to
do so. A small percentage of people have
reactions to immunizations that require
appropriate medical treatment. There are
other issues, such as the handling of hypo-dermic
needles, that require appropriate
training to prevent the spread of infection
and viruses such as HIV and hepatitis.
Immunizations require appropriate med-ical
control, which means a prescription
from an authorized practitioner and an
appropriate protocol for delegation of
administration to other practitioners,
including appropriate management of the
serum and the hypodermic needles. You
do not want serum that is out of date or
has been improperly stored or needles that
may transmit infection.
In short, there is a good reason for the
protections afforded by your state licens-ing
system, including the licensing or
approval of physicians, pharmacists,
physician assistants, advanced practice
nurses, nurses, paramedics, and other
health practitioners involved in this recov-ery
effort. Any waiving of the require-ments
would only compound risks for
those already suffering as a result of this
disaster. u
Hurricane Floyd
Andrew W. Watry
Executive Director, NCMB
No. 3 1999 11
The relationship between a physician and
a patient is based on trust and mutual confi-dence.
The North Carolina Medical Board
identifies multiple elements that are neces-sary
for maintaining a patient’s trust. (See
the NCMB’s position statement: The
Physician-Patient Relationship.) Among the
elements identified are respect for a patient’s
autonomy, the assurance of confidentiality,
and adequate communication between
physician and patient. During the course of
the physician-patient relationship, it is very
likely that a physical examination, which
includes deliberate examination and touch-ing
of the patient by the health care provider,
will occur.
Reassuring the Patient, Protecting
the Physician
Chaperones have long been used for gyne-cologic
examina-tions
and proce-dures.
The third
party serves not
only to provide
reassurance to the
patient and to assist
the physician, but
also to protect the
physician against
unfounded accusa-tions
of inappropri-ate
behavior.
Allegations that health care providers have
committed sexual improprieties against
patients are infrequent. Despite their rarity,
allegations of sexual misconduct have been
brought against physicians and dentists prac-ticing
in such diverse fields as family prac-tice,
psychiatry, anesthesiology, general den-tistry,
and endodontics. When allegations of
sexual improprieties are made, the accused
faces the devastating aftermath of emotional
turmoil, damage to professional credibility,
possible criminal charges, and costly civil
actions.
How are health care providers using chap-erones?
Studies reflect that the use of chap-erones
during female genital examination
varies by sex of the
health care provider.
One study of family
physicians noted
that 79.4% of male
physicians and
31.9% of female
physicians surveyed
used chaperones
during female geni-tal
examinations.
The same study
noted the rate of chaperone use during male
genital examination was 1.4% for male
physicians and 14.4% for female physicians.1
Another study of primary care physicians
reported higher chaperone use during female
genital examination: 96.9% for male physi-cians
and 64.0% for female physicians.2
The study of chaperone use has now
expanded to include health care providers
who care for patients whose mental status
may be altered by the use of sedatives, hyp-notics,
anxiolytics, or analgesics, or by recov-ery
from anesthesia. A patient awakening
from anesthesia may misinterpret a touch or
even imagine a sexual advance that did not
happen.
Many dentists who use sedation during
procedures have made having a third party
in the room a standard operating procedure.
Anesthesiologists are usually providing anes-thesia
care in the presence of a room full of
their peers. However, sexual assaults have
occurred in pre-operative holding areas and
recovery rooms. In a California case, an
anesthesiologist drew the curtains around
the stretchers of several female patients in
order to conceal his assaults.3
What Can You Do?
What can you do as a health care provider
to protect yourself against unfounded accu-sations
of sexual misconduct? The North
Carolina Medical Board’s current position
statement on the subject, Guidelines for
Avoiding Misunderstandings During
Physical Examinations, states that:
Whatever the sex of the patient, a third
party should be readily available at all
times during a physical examination,
and it is advisable that a third party be
present when the physician performs an
examination of the breast(s), genitalia,
or rectum. When appropriate or when
requested by the patient, the physician
should have a third party present
throughout the examination or at any
given point during the examination.
Current risk management recommenda-tions
from Medical Mutual advise the use of
a chaperone for all physicians conducting
any type of physical examination in which
removal of clothing is involved. The pres-ence
of a chaperone is strongly recommended
if a physician and patient are of different
genders and an examination involves cloth-ing
removal. It should be noted that these
recommendations apply to patients of all age
groups.
As stated previously, chaperones have
been most frequently used during female
genital examinations. In consideration of
the prevailing liti-gious
climate, chap-erones
should be
considered for male
genital examinations.
As a physician, the
issue of a chaperoned
examination should
be addressed with
the patient prior to
the examination.
Should a patient
refuse a chaperone,
this refusal should be documented and ini-tialed
by the patient.
Because physicians are continually asked
to “do more with less,” your practice may
view the use of chaperones as a poor use of
resources. The use of chaperones does
require staff coordination and may result in
increased time between patient examina-tions.
However, the cost of being falsely
accused of sexual misconduct in a victim-ori-ented,
tabloid-saturated society cannot be
underestimated.
————————————
Notes
1. Gilchrist, Gillanders, Gemmel: Chaperoning
Practices of Ohio Family Physicians. Family
Medicine, July 1992; Vol 24, No 5: 386-389.
2. Renfroe, Replogle: Chaperone Use in Primary
Care. Family Medicine, March-April 1991; Vol 23,
No 3: 231-233.
3. Anesthesia Malpractice Prevention. April 1996;
Vol 1, No 4: 25-27.
————————————
Reprinted in edited form from Medical Mutual’s
quarterly MedNotes, Summer 1999. u
Don’t Underestimate the Importance of Chaperones
Naomi M. Tsujimura, RN, CCRN
Claims Department, Medical Mutual Insurance Company of North Carolina
Ms Tsujimura
“One study noted
79.4% of male
physicians and
31.9% of female
physicians sur-veyed
used chap-erones
during
female genital
examinations.”
“A chaperone is
strongly recom-mended
if a
physician and
patient are of
different genders
and an examina-tion
involves
clothing
removal.”
“Despite their
rarity, allegations
of sexual miscon-duct
have been
brought against
physicians and
dentists practicing
in diverse
fields ”
12 NCMB Forum
Forum
Beginning in 2000, the Forum will be
available to commercial organizations
and a number of other groups and indi-viduals
only via the Internet. The North
Carolina Medical Board’s Web site
(www.docboard.org/nc) has been presenting
the Forum, exactly as it appears in its print-ed
form, since late 1998. To access it only
requires the Adobe Acrobat Reader, which
can be downloaded free at www.adobe.com,
and the Board’s Web site provides a quick
link to the Adobe site. Using the Adobe
Acrobat Reader, the Forum can be easily
read on screen and readily printed out.
This has been the general public’s major
access to the Forum for the past year.
(Should you have trouble with this
process, please contact Jennifer Deyton of
the Board’s Public Affairs Department.
She can be reached by telephone at 1-919-
326-1100, ext 271, or by e-mail at pub-lic.
affairs@ncmedboard.org.)
We find this approach an effective way
of dealing with the constantly growing
demand for the Forum on the part of a
very wide spectrum of readers. From a
practical point of view, only so many
copies of the Forum can be published and
mailed each quarter. However, this elec-tronic
system allows those who have an
interest in the Forum, the diverse articles
and the data it presents, to receive it if
they have access to the Internet in home,
office, or library. Therefore, should you
not receive the first number of the Forum
for 2000 by early April 2000, check the
Internet. The new number will be there
or a notice will be posted telling you when
to expect its appearance.
Bimonthly Board Action Reports
and Immediate Action Notices
For almost five years, the North
Carolina Medical Board has been sending
a Bimonthly Board Action Report, listing
all its public actions relating to physicians,
physician assistants, and nurse practition-ers,
to hospitals, medical groups, and the
news media. It has also issued Immediate
Action Notices for actions involving
annulments, revocations, suspensions,
summary suspensions, and license surren-ders.
These notices go out as soon as the
AHCPR and Other
Guidelines on Pain
Available
Among its many other activities over the
past decade, the Agency for Health Care
Policy and Research (AHCPR) of the U.S.
Public Health Service has facilitated devel-opment
of clinical practice guidelines on a
variety of topics. Three of these, published
from 1992 to 1995, deal with the manage-ment
of pain. They include Acute Pain
Management: Operative or Medical Procedures
and Trauma; Management of Cancer Pain;
and Acute Low Back Problems in Adults.
Several versions of each guideline are
available. The “Clinical Practice Guideline”
presents recommendations for health care
providers with brief supporting information,
tables and figures, and pertinent references.
“The Quick Reference Guide for Clinicians”
is a distilled version of the “Clinical Practice
Guideline,” with summary points for ready
reference on a day-to-day basis. “The
Consumer Version (or Patient Guide),”
available in English and Spanish, is an infor-mation
booklet for the general public to
increase patient knowledge and involvement
in health care decision making.
To order single copies of these (or any)
AHCPR guideline publications or to obtain
further information, call the AHCPR
Publications Clearinghouse toll-free at 800-
358-9295 or write to: AHCPR Publications
Clearinghouse, PO Box 8547, Silver Spring,
MD 20907.
Also available is the fourth edition of
Principles of Analgesic Use in the Treatment
of Acute Pain and Cancer Pain (1999)
from the American Pain Society, 4700
West Lake Avenue, Glenview, Illinois
60025-1485. The APS’ Web site address is
http://www.ampainsoc.org/.
The World Health Organization has sever-al
titles dealing with the relief of cancer pain
and palliative care. These include the second
edition of Cancer Pain Relief with a Guide to
Opioid Availability (1996), Cancer Pain Relief
and Palliative Care in Children (1998), and
Symptom Relief in Terminal Illness (1998).
For further information on these publica-tions,
contact Distribution and Sales, World
Health Organization, 1211 Geneva 27,
Switzerland. u
Electronic Distribution to Be Used for Some
Forums, Bimonthly Board Action Reports,
Immediate Action Notices
actions occur and make the information
available at once, not delaying it until the
next bimonthly release. Due to cost con-straints,
the Board has focused over these
years on sending these materials only into
those counties in which the involved
physicians, PAs, or NPs actually practiced
and to relevant state agencies. As with
the Forum, which reprints the reports
for statewide circulation, the Bimonthly
Board Action Reports and the Imme-diate
Action Notices have been appear-ing
on the Board’s Web site
(www.docboard.org/nc) since 1998. In fact,
we are now posting a full year’s worth of
the bimonthly reports, allowing the Web
user to go back over the year’s activity.
Anyone with access to the Internet can
easily review these reports and notices: the
public, hospitals, medical groups, the
media, other state agencies, other states,
etc.
We want all the state’s hospitals, med-ical
groups, news media, and relevant
organizations to know that we would like
to notify them by e-mail each time a new
report or notice has been posted. This
notification system would ensure quick
statewide distribution of the material, not
limited simply to the counties in which
the involved practitioners may practice.
Any hospital, medical group, newspaper
or journal, television or radio station, or
interested organization that makes its e-mail
address available to us in writing or
by e-mail will be made a part of this noti-fication
system. That will make it unnec-essary
for us to mail a printed copy of the
particular Bimonthly Board Action
Report or Immediate Action Notice to
that institution, organization, or person,
saving time and costs on both sides.
If you wish to participate in this system,
please send the appropriate e-mail address,
along with your name or the name of the
responsible person, and the name and
address of your institution, organization,
or other affiliation, to: Jennifer Deyton,
Public Affairs Department, North
Carolina Medical Board, PO Box 20007,
Raleigh, NC 27619; or e-mail the same
information to Ms Deyton at
public.affairs@ncmedboard.org. u
North Carolina Medical Board
E-Mail:
ncmedbrd@interpath.com
No. 3 1999 13
North Carolina Physician Demographics: 1979-1998
Michael J. Pirani, PhD, Director, Health Professions Data System, Sheps Center for Health Services Research, UNC, Chapel Hill
Thomas C. Ricketts, PhD, MPH, Deputy Director, Sheps Center for Health Services Research, UNC, Chapel Hill - Director, Rural Health Research Program.
The demographic structure of North
Carolina’s physician work force has undergone
significant changes over the last 20 years. The
proportion of women physicians is increasing
every year, and the age structure of the state’s
physicians is also changing. Physician demo-graphic
characteristics are not homogenous
across the state, as physicians in rural counties
are older on average and there are proportion-ally
fewer rural women physicians than urban.
This report is another in a series of analyses
made possible by 20 years of cooperation
among the North Carolina Medical Board, the
North Carolina Area Health Education Centers
(AHEC) Program, and the Cecil G. Sheps
Center for Health Services Research at the
University of North Carolina at Chapel Hill.
The North Carolina Medical Board has shared
descriptive information contributed by licensed
physicians as part of the annual registra-tion
process with the Sheps Center since
1976. The Center has published an
annual report and has conducted numer-ous
analyses for policy makers and pro-fessional
associations using these data.
The data used to produce this report are
the property of the North Carolina
Medical Board and are released only with
permission of the Board or its executive
director.
North Carolina Physicians’ Age
and Sex Distribution
In 1979, women made up 5.8% of
North Carolina’s active physician work
force [Figure 1]. Over one quarter
(27.4%) of the state’s physicians were 55
years of age or older, and 16.2% were
under 35 years old.
By 1988, the physician work force had
become dramatically younger [Figure 2]. This
was due to large increases in younger physi-cians
rather than loss of older doctors, as the
total number of physicians 55 or over had
increased. The proportion of physicians in the
35 to 54 range had not changed much from
1979 (56.5% to 55.1%), but the percentage of
physicians 55 and over had declined to 22.1%,
while the proportion of physicians under 35
had risen over 40% to 22.8%. The proportion
of female physicians in the state had more than
doubled to 12.5%, as nearly
one quarter (24.2%) of the
physicians under 35 years of
age were women.
The percentage of women
physicians practicing in the
state continued
to rise into
1998, when
more than one
in five physi-cians
(20.2%)
were women
[Figure 3].
The propor-tion
of female
physicians will
continue to
approach that
of males in the
future, as over
one third (36.4%) of the state’s
physicians under 35 years of
age were women, as were 39%
of the physicians younger than
30 years of age.
Nearly two thirds (64.7%)
of North Carolina’s physicians were between
the ages of 35 and 54 in 1998. The percentage
of physicians under 35 had declined to a 20-
year low of 15.6%, after a peak of 24.2% in
1983. There were fewer older physicians in the
state’s work force as well, as fewer than one
fifth (19.7%) of North Carolina’s physicians
were 55 years of age or older, the lowest per-centage
in the last 20 years.
Physician Demographics in Rural
North Carolina
In 1979, rural North Carolina had a higher
proportion of older physicians than the state,
with over one third (33.4%) being 55 years of
age or older. Women physicians were also
scarcer in non-metropolitan areas of the state
(see note), accounting for less than one twenti-eth
(4.6%) of the total. By 1988, the percent-age
of physicians 55 years of age or older had
declined by 18% to 28.4%. A higher propor-tion
of rural physicians was 55 or older than in
urban areas of the state in 1998, with 22.3% of
rural physicians being 55 or older. However,
there were similar proportions of physicians
between 35 and 54 (63.0% rural vs 65.2%
urban) and physicians under 35 (14.7% rural
vs 15.6% urban) compared to the rest of the
state. The proportion of women physicians in
rural North Carolina had increased sharply to
17.1%, with women accounting for 34.0% of
rural physicians under 35 years of age.
Although this is still a slightly lower proportion
than for the state, it represents a greater pro-portional
rate of increase in the period from
1988 to 1998 (67.1% to 61.7%).
Conclusions
The supply of physicians in North
Carolina is not subject to substantial
changes due to retirement or death. In
1998, the proportion of the state’s physi-cian
work force between the ages of 35
and 54 was the highest it had been in 20
years. This indicates that the supply will
remain stable over the near term. The
number of licensed, active physicians
who are women has grown rapidly since
1978; however, it will take many years
for the number of male and female physi-cians
to near equality.
————————————
Note
To consistently compare the urban-rural
distribution of physicians across 20 years, the
1993 OMB metropolitan definitions were used
for all the years studied.
Sources
North Carolina Health Professions Data Book, Cecil
G. Sheps Center for Health Services Research,
1979,1988,1998. u
PA/NP R
14 NCMB Forum
Effective May 1, 1999, the North Carolina Medical Board made
several changes to the physician assistant (PA) and nurse practitioner
(NP) rules. Our focus here will be on changes to the prescribing
authority of PAs and NPs. Requirements retained from the old rules
are restated; changes are highlighted in bold type. Rule references
are to the new rules.
Physician Assistants
PA Rules (21 NC Administrative Code Chapter 32, Subchapter S)
Documentation Requirements:
l Every PA must maintain at all approved practice sites written pre-scribing
instructions, signed by the PA and the supervising physi-cian(
s) (“SP”), which contain specific instructions from the SP to
the PA regarding prescribing, ordering, and administering drugs
and medical devices, and a policy for periodic review by the SP
of the PA’s prescribing, ordering, and administering drugs and
medical devices. [PA Rule .0109(2)] In addition, the new
rules state the PA and SP must acknowledge that each is
familiar with the laws and rules regarding prescribing and
agree to comply with these laws and rules by incorporating
them into the written prescribing instructions. [PA Rule
.0109(1)]
l Each prescription must be documented in the patient’s record
and include medication name and dosage, amount prescribed,
directions for use, number of refills, signature of the PA, and
cosignature by the SP within the time limits set forth in PA Rule
.0110(c). [PA Rule .0109(6)]
Prescribing Controlled Substances:
l In order to prescribe controlled substances, both the PA and the
SP must have a valid DEA registration. [PA Rule .0109(4)]
l In order to prescribe controlled substances, the old rule required
the PA and SP to sign a statement that they had read and under-stood
“the DEA MID-LEVEL PRACTITIONERS MANUAL
and the information sheet provided by the Board.” The new
rules do not mention this manual but, instead, state the PA
and SP “shall prescribe in accordance with information pro-vided
by the Medical Board and the DEA.” [PA Rule
.0109(4)]
l The old PA rule limited prescriptions for substances falling with-in
the categories 2, 2N, 3, and 3N to a legitimate seven day sup-ply.
The new PA rule states prescriptions for substances
falling within these categories “shall not exceed a legitimate
30 day supply.” [PA Rule .0109(4)]
NOTE REGARDING PRESCRIBING OF SCHEDULES 2, 2N,
3, AND 3N CONTROLLED SUBSTANCES: The PA rules do
not prohibit a PA from prescribing refills of category 2 and 2N
substances but current DEA regulations do not permit this. A
PA may write refills for 3 and 3N controlled substances but, as
stated above, the total amount prescribed, including refills, may
not exceed a legitimate 30 day supply.
Prescription Forms:
l Each prescription issued by a PA shall contain the PA’s name,
practice address, and telephone number; the PA’s license number
and, if controlled substances are prescribed, the PA’s DEA regis-tration
number; and the SP’s name and telephone number. [PA
Rule .0109(5)]
Professional Medication Samples:
l PAs who request, receive, and dispense to patients professional
medication samples must comply with all applicable state and
Recent Changes to PA and NP Prescribing Rules
R. David Henderson, JD
NCMB Legal Department
federal regulations. [PA Rule .0109(7)]
Compounding and Dispensing Drugs:
l In order to compound and dispense drugs, PAs must obtain
approval from the North Carolina Board of Pharmacy and follow
all Board of Pharmacy rules and federal guidelines. [PA Rule
.0109(3)]
Procuring Drugs:
l Language added at the beginning of PA Rule .0109 now per-mits
PAs to procure and dispense drugs and medical devices.
This is in addition to permission granted in theold rules to
“prescribe, order, and administer.”
Nurse Practitioners
NP Rules (21 N.C. Administrative Code Chapter 32, Subchapter M)
Documentation Requirements:
l Every NP must maintain at all practice sites written protocols
(formerly known as written standing protocols), signed by the
NP and the SP, which specify, among other things, the drugs and
devices that may be prescribed, ordered, and implemented by the
NP. [NP Rules .0109(b)(3) and .0108(b)(1)]
l Each prescription shall be noted on the patient’s chart and
include medication and dosage, amount prescribed, directions
for use, number of refills, and signature of the NP. [NP Rule
.0108(b)(5)]
Controlled Substances:
l An NP may prescribe or order controlled substances so long as
he/she has a valid DEA registration number which is entered on
each prescription for controlled substances. [NP Rule
.0108(b)(2)(A)] The new rules also allow an NP to procure
controlled substances so long as he/she has a valid DEA reg-istration
number. [NP Rule .0108(b)(2)]
l With a few exceptions, the old NP rules limited prescriptions for
substances falling within categories 2, 2N, 3, and 3N to a seven
day supply. The new NP rule states prescriptions for sub-stances
falling within these categories “are limited to a 30
day supply.” [NP Rule .0108(b)(2)(B)] Prescriptions for
these schedules may not be refilled. [NP Rule .0108(b)(2)(C)]
However, since current DEA regulations do not permit refills of
category 2 and 2N substances, this restriction applies, in effect,
only to category 3 and 3N substances.
Other Prescribing Requirements:
l NPs may prescribe a drug not listed in the written protocols only
if (1) there is a specific written or verbal order from the SP before
the prescription or order is issued by the NP, and (2) said writ-ten
or verbal order is entered in the patient record with a nota-tion
that it is issued on the specific order of the SP and the nota-tion
is signed by the NP and SP. [NP Rule .0108(b)(3)] See also
NP Rule .0101(11) (“ . . . Clinical practice issues that are not
covered by the written protocols require nurse practition-er/
physician consultation, and documentation related to the
treatment plan.”)
l Refills may be issued for a period not to exceed one year; how-ever,
as noted above, schedules 2, 2N, 3, and 3N may not be
refilled. [NP Rule .0108(b)(4)]
Prescription Forms:
l All prescriptions issued by an NP shall contain the SP’s name, the
name of the patient, and the NP’s name, telephone number, and
prescribing number assigned by the Medical Board. In addition,
continued on page 15
No. 3 1999 15
if a controlled substance is prescribed,
the prescription shall contain the NP’s
DEA registration number. [NP Rules
.0108(b)(6) and (7)]
Dispensing Drugs:
l An NP may obtain approval to dispense
the drugs and devices specified in the
written protocols from the North
Carolina Board of Pharmacy and must
dispense in accordance with all Board of
Pharmacy rules. [NP Rule .0108(c)]
Summary
Most of the language from the old PA and
NP prescribing rules remains in effect.
However, the new PA rules require the PA
and SP to acknowledge that each is familiar
with the laws and rules regarding prescribing
and agree to comply with these laws and
rules by incorporating them into the written
prescribing instructions. While PAs are no
longer required to read the DEA Mid-Level
Practitioners Manual, they are required to
prescribe in accordance with information
provided by the Medical Board and the
DEA. PAs may now prescribe categories 2,
2N, 3, and 3N substances in an amount not
to exceed a legitimate 30 day supply. Due to
DEA regulations, prescriptions for cate-gories
2 and 2N may not be refilled.
Prescriptions for categories 3 and 3N may be
refilled so long as the total amount pre-scribed
does not exceed a legitimate 30 day
supply. Finally, PAs may now procure and
dispense drugs and medical devices.
The new NP rules also permit NPs to pre-scribe
a 30 day supply of substances falling
within categories 2, 2N, 3, and 3N; howev-er,
as before with the old rules, refills are
expressly prohibited. Under the new rules,
NPs are now permitted to procure con-trolled
substances, in addition to prescribe
and order, so long as the NP has a valid DEA
registration and this is permitted by the writ-ten
protocols. Finally, if an NP prescribes a
drug not listed in the written protocols, the
new rules require the SP to co-sign the NP’s
notation of this prescription in the patient
record.
Copies of the PA and NP rules
may be ordered by leaving a message at
1-800-253-9653, ext. 269 (NC & VA) or
1-919-326-1109, ext. 269. Also, these
rules can be found on our Web site at
www.docboard.org/nc. Click on Rules in the
directory. The PA prescribing rules begin at
page 53 and the NP prescribing rules begin
at page 42. u
Recent Changes to PA/NP
Prescribing Rules
continued from page 14
REVIEW
The challenge usually comes in two
forms:
l “Doctor, please stop it. We all have to die.
This is futile.”
l “Care at the end of life is one of the biggest
costs in medicine. You doctors will just have
to learn to avoid that expense. It’s futile.”
Both statements are true. Neither is usu-ally
very useful. Who among us has not
wrestled with these thoughts at the bedside
of the elderly patient on dialysis? Who has
not grappled with the decision to open the
chest of a boy in cardiac arrest who is lifeless,
shot 20 minutes earlier through the chest?
The decision when to stop treatment or
progress from therapy to palliation remains
one of medicine’s great challenges, especially
in this decade of increasing technology, mea-sures
that now enable life in situations previ-ously
regarded as hopeless. Accordingly, I
was delighted to run across When Doctors Say
No: The Battleground of Medical Futility by
Susan B. Rubin, a “philosopher and bioethi-cist,
a co-founder of The Ethics Practice, a
California firm devoted to providing
bioethics education, research, and clinical
consultation.” Ahh, here is an expert who
may illuminate this dark tunnel of our prac-tice.
What a disappointment. She not only
fails to address the two real challenges noted
in my first paragraph, she replaces these with
a flimsy third thesis. She claims that physi-cians
make decisions about medical futility
on their own without consulting others. She
rejects “the popular arguments supporting
unilateral decision making by physicians and
calls instead for a different kind of conversa-tion
about the central values at stake when
doctors and patients so dramatically dis-agree.”
Dr Pories
When Is It Futile?
Walter J. Pories, MD
Member, NCMB
Dr Rubin, you need to get out more. In
my many years of practice in a variety of set-tings,
ranging from trauma centers to small
hospitals, as well as military hospitals during
our wars, I rarely found a physician making
a unilateral decision regarding the futility of
treatment. In contrast, I encountered just
the opposite. Physicians invariably seek help
and advice from families, friends, colleagues,
nurses, social workers, ministers, and ethi-cists
before cessation of treatment. Further,
“dramatic disagreements” between doctors
and patients are also a rare occurrence. No,
instead we often sit long hours with patients
and their families, pondering the future and
how to address it with kindness, control of
pain, husbandry of resources, and affection.
Even at the end of the drama of failed car-diac
arrest, the senior physician will always
ask, “I think it’s time. Agree?” Deciding
when someone is to die is too heavy a deci-sion
for us, as physicians, to make alone. In
contrast to Dr Rubin’s contention, we do
not reject advice, we seek it.
___________________________
When Doctors Say No: The Battleground of
Medical Futility
Susan B. Rubin
(in the Medical Ethics Series, edited by
Smith and Veatch)
Indiana University Press, Bloomington and
Indianapolis, 1998
191 pages (notes, bibliography, index),
$24.95 cloth
(ISBN 0-253-33463-2)
___________________________
Unfortunately, Dr Rubin concentrates on
a non-issue and misses the big one: how do
we know when our therapies will be futile?
I have seen a young Air Force sergeant
recover apparently full faculties after two
years of coma. When I ran the Hospice in
Cleveland, Ohio, we were sent a moribund
woman with massive metastatic breast can-cer,
clearly ready to die, who, after we treat-ed
her with hydration, hormones, and
chemotherapy, lived another five years, long
enough to watch her children graduate from
high school. On the other side of the coin,
I have also despaired at the costs, both fiscal
and emotional, incurred by the septic patient
with necrotizing fasciitis who finally died
after a number of operations and months in
continued on page 16
Logo behind text
16 NCMB Forum
When is it Futile?
continued from page 15
continued on page 17
the intensive care unit.
Dr Rubin’s failure to focus may be due to
her turgid writing: “My conceptual analysis
of futility will treat each epistemological
question separately.” Or how about this sen-tence?
Though the leaky bucket metaphor
and its underlying presumptions
have been used, perhaps unwit-tingly,
to support normative argu-ments
in favor of physician author-ity
to refuse unilaterally to provide
treatment on the grounds of futili-ty,
neither the metaphor nor its
underlying presumptions are prob-lem
free.
That’s tough reading, and not worth the
time. Too bad, too; the challenge of “futili-ty”
deserves far more emphasis. As a society,
we need to address this issue. Do we follow
the lead of our British colleagues who ration
by resources, the Colorado Medicaid format
that limits by a list of therapies, or do we
continue to muddle on with continuing
arguments about cost while ignoring com-passion?
Where are the data to help us make
these decisions?
We are still waiting for the book that will
help us with these decisions. So far, the
Bible and the Koran still seem to be the best
authorities. Let me recommend that you
continue to read these two references until
something better than Dr Rubin’s book
comes along. u
LETTER TO THE EDITOR
Two Questions:
Romantic Relationships,
Splitting Fees
To the Editor: Ever since I read a scenario in
the Forum, I have wondered whether there
was more to the story than was written
because it raised questions about what I
think may be a common circumstance, espe-cially
in smaller towns. The item appeared
sometime in the past year or so. [Forum #4,
1997, page 24.]
As I recall, the case concerned a male MD
in a multi-physician group who gave a phys-ical
to one of the female employees who did
not work directly for or with him. Some
time after this, they started dating and hav-ing
a sexual relationship. The Forum indi-cated
that the man’s license was suspended,
placed on probation, or canceled—I can’t
recall which, but any of the three sounded
awfully severe. (And who filed the com-plaint
that brought it to the Board’s atten-tion
anyway? The employee? Another, per-haps
jealous, employee or patient? Or some
anonymous observer? Does that make a dif-ference?
Who or what determines “no
harm, no foul”?) Would it have made a dif-ference
if the employee worked directly for
or with the doctor, was paid by him?
I understand that “consensual,” in some
instances (eg, professor and student, CEO
and middle manager), may raise questions,
per se, of propriety/ethics, but where is the
line drawn? A patient who happens to be
the mayor is inherently in a position that
may make the doctor actually the one who
could be “beholden.” (An “inherently
unequal” relationship actually is the norm
for almost any relationship, if you choose to
see it that way.) “The very appearance of
impropriety is enough to assume impropri-ety”?
If so, “impropriety” in whose eyes?
Also, eg, how many wives work in their hus-bands’
offices, whether in a clinical or a non-clinical
capacity? (And does the latter dis-tinction
make any difference?) If that is all
right, what if they were just engaged or just
dating? At what point is it questioned by
the Board?
Does someone have to file a complaint?
And does that someone have to be verified
as not having his or her own ax to grind in
the situation?
So, my question concerns to what length
the North Carolina Medical Board takes this.
For example, if I, as a specialist, am asked to
see a patient in consultation for a brief peri-od
of time, does that mean that if I am asked
out to dinner by that (former) patient five
years later I am unethical if I accept and
could have my license yanked and black
marks on my record forever? Or, if I am
already friends with that person from church
or school or if I am already dating that per-son,
if they come to me because they already
know me, and we continue or start to date,
is that relationship with the patient unethical
in the Board’s eyes? And what does the
parameter of during or after—and how long
after—the limited doctor-patient interaction
matter? What if it is an ongoing but inter-mittent
relationship, such as sewing a lacera-tion
or freezing a wart? If there is any mid-dle
ground, does it revolve around whether
or not there is a sexual component? If so,
how sexual? What makes a difference to the
Board: a good-night kiss, a thank-you hug,
an arm around the shoulder, holding hands,
or a Clintonesque contact?
It seems there’s an awfully slippery slope
here. Especially in a small town there may
be “slim pickins” for a single doctor who is
still interested in having relationships, and
the odds are high that some of the scenarios
I’ve suggested could obtain.
Perhaps I misread the original article, but
I believe you can tell where I would like
some clarification.
Also, in that same issue [#4, 1997, page
13], there was a reference to not being
allowed to split profits with other health care
workers, except as allowed under a specific
statute, which was not explained. Could you
explain that statute? And does this mean
that if a more experienced associate (but not
legal partner) of mine or even someone in
another practice helps me on a complicated
procedure that I am not allowed to say thank
you in a monetary way? (Say a procedure
not allowed to be coded for an assistant’s
fee.)
Thanks in advance for responding to my
concerns.
A North Carolina Physician
Response
Volumes have been written on your first ques-tion
and I’ll not try to reproduce them here.
Your description might apply to several recent
cases, so I’ll also not try to elaborate on any par-ticular
case. There would be further public
record beyond what was in the Forum, but the
Forum is usually a close paraphrase of the legal
documents in the public record.
Informative Video Tapes
The Magic Kiss: Sexual Misconduct and
Boundary Violations [114 minutes; 1997]
A seminar conducted at the offices of the NCMB
by Barbara S. Schneidman, MD, MPH, then
Associate Vice President of the American Board of
Medical Specialties and now Director of the AMA
Office of Medical Education Liaison and
Outreach. This is the presentation Dr
Schneidman has made before a number of state
medical boards and other medical groups over the
past several years. Available from the NCMB’s
Public Affairs Office for $10.00 (which
includes mailing charge). (Please inquire for
costs if requesting shipping outside the U.S.)
Edmund D. Pellegrino: “Why Do We
Speak of Responsibility?” [25 minutes;
1994]
Distinguished medical ethicist discusses the duties
of medical board members, the ethics of medical
practice, and the role of medical educators. Dr
Pellegrino is Director of the Center for Clinical
Bioethics at Georgetown University Medical
Center. Available from the NCMB’s Public
Affairs Office for $12.95 (which includes mail-ing
charge). (Please inquire for costs if
requesting shipping outside the U.S.) u
No. 3 1999 17
Letter to the Editor
continued from page 16
North Carolina Medical Board
Meeting Calendar, Application Deadlines, Examinations
November 1999 -- September 2000
Board Meetings are open to the public, though some portions are closed under state law.
North Carolina Medical Board November 17-20, 1999
November Meeting Deadlines:
Nurse Practitioner Approval Applications October 4, 1999
Physician Assistant Applications October 6, 1999
Physician Licensure Applications November 2, 1999
North Carolina Medical Board January 19-22, 2000
January Meeting Deadlines:
Nurse Practitioner Approval Applications December 6, 1999
Physician Assistant Applications November 24, 1999
Physician Licensure Applications January 4, 2000
North Carolina Medical Board March 15-18, 2000
March Meeting Deadlines:
Nurse Practitioner Approval Applications January 31, 2000
Physician Assistant Applications January 28, 2000
Physician Licensure Applications February 29, 2000
North Carolina Medical Board May 24-27, 2000
May Meeting Deadlines:
Nurse Practitioner Approval Applications April 10, 2000
Physician Assistant Applications March 24, 2000
Physician Licensure Applications May 9, 2000
North Carolina Medical Board July 19-22, 2000
July Meeting Deadlines:
Nurse Practitioner Approval Applications June 5, 2000
Physician Assistant Applications July 5, 2000
Physician Licensure Applications July 3, 2000
North Carolina Medical Board September 20-23, 2000
September Meeting Deadlines:
Nurse Practitioner Approval Applications August 7, 2000
Physician Assistant Applications September 5, 2000
Physician Licensure Applications September 5, 2000
Residents Please Note USMLE Information
United States Medical Licensing
Examination Information
(USMLE Step 3)
The May 1999 administration of the USMLE Step 3 was the last
pencil and paper administration. Computer-based testing for Step 3
is expected to be available on a daily basis in November 1999.
Applications may be obtained from the office of the North Carolina
Medical Board by telephoning (919) 326-1100. Details on administra-tion
of the examination will be included in the application packet.
Special Purpose Examination (SPEX)
The Special Purpose Examination (or SPEX) of the Federation of
State Medical Boards of the United States is available year-round.
For additional information, contact the Federation of State Medical
Boards at 400 Fuller Wiser Road, Suite 300, Euless, TX 76039 or
telephone (817) 868-4000.
*
Each case is decided on its own facts.
Generally, in “boundary violation” cases, as we
generically refer to them, we are looking for an
abuse of the power differential inherent in the
physician/patient relationship, just as you sug-gest.
Abuses of the power differential in the
employment relationship, coupled with dissolved
or dissolving boundaries in the physician/patient
relationship, might be worrisome in themselves
or suggestive of worse things to come. Treating
anyone with whom the physician has a
personal or other relationship (beyond the physi-cian/
patient relationship) could also be consid-ered
a boundary violation, though perhaps a less
severe one. It also frequently leads to care pro-vided
to a lower standard than that provided
those who are simply patients.
The Board gets its information from a variety
of sources. For the Board to have acted, either
the physician must have admitted the conduct in
the accusation or the Board must have proven it.
An unverified complaint from someone with an
ax to grind might get an investigation started,
but it usually won’t win at trial.
Exploitation of the power differential being
the issue, the more recent and extensive the con-tact
between patient and physician, the more
likely the Board is to see a problem. Standards
certainly were different in the past when many
communities had only one physician and when
physicians generally did not go outside their
communities for dates or anything else. In 1999
North Carolina, the Board might doubt your
“small town defense.”
Your reference to the statutory “exception” to
the prohibition against fee splitting is probably
NC Gen Stat 55B-14(c), the one allowing
physicians and certain others to own shares
together in a single professional corporation (eg,
psychiatrists and psychologists; ophthalmologists
and optometrists).
Thanks for reading the Forum.
James A. Wilson
Director
NCMB Legal Department u
Audio Tape: “End-of-
Life Decisions Forum”
End-of-Life Decisions Forum [4 hours;
1998]
Transcription of a conference developed and pre-sented
by the staffs of the North Carolina Medical
Board, the North Carolina Board of Nursing, and
the North Carolina Board of Pharmacy. Held in
Raleigh, North Carolina, on October 23, 1998,
the conference was designed to provide a forum
for health care regulators, professionals, and poli-cy
makers to explore the ethical, legal, and other
issues surrounding end-of-life decisions and to ini-tiate
a continuing process for addressing such
issues. Speakers included Lawrence O. Gostin,
JD, LLD (Hon), Co-Director of the Johns
Hopkins University and Georgetown University
Program on Law and Public Health; George C.
Barrett, MD, Vice President of the Federation of
State Medical Boards and past president of the
North Carolina Medical Board; Anne Dellinger,
JD, Professor of Public Law and Government at
the University of North Carolina; Bill Campbell,
PhD, Dean of the University of North Carolina
School of Pharmacy; David A. Swankin, JD,
President of the Citizen Advocacy Center; Nancy
M.P. King, JD, Associate Professor of Social
Medicine at the University of North Carolina;
Sharon Dixon, RN, MPH, Senior Vice President
of Clinical Services at the Hospice of Charlotte;
Joseph A. Buckwalter, MD, President of the
North Carolina Hemlock Society; Cathy Clabby,
MA, Medical Reporter for the Raleigh News and
Observer; and the executive directors of the three
host boards. On two 120 - minute audio cas-settes.
Available from the NCMB’s Public
Affairs Office for $10.00 (which includes mail-ing
charge). (Please inquire for costs if
requesting shipping outside the U.S.) u
18 NCMB Forum
ANNULMENTS
NONE
REVOCATIONS
NONE
SUSPENSIONS
TRITES, Paul Nathan, MD
Location: Richfield, MN
DOB: 8/13/1953
License #: 0000-27326
Specialty: OPH/IM (as reported by physician)
Medical Ed: University of Minnesota (1980)
Cause: A hearing before the Board on 5/20/1999 on charges dated
10/06/1998. Dr Trites was disciplined by the Minnesota Board
of Medical Practice on or about 1/10/1998 for failure to record
adequate information in the medical records of three patients,
failure to promptly provide medical records to two patients, and
failure to cooperate with the Minnesota Board’s investigation of
his practice. In testimony before the North Carolina Medical
Board, he continued to blame former staff members and attor-neys
for the problems cited. He presented a copy of an Order of
Unconditional License dated 3/13/1999 in which the Minnesota
Board conferred on him an unconditional license to practice;
however, he did not prove to the North Carolina Board that he
has corrected the underlying problems that led to the discipline
imposed by Minnesota.
Action: 6/10/1999. Findings of Fact, Conclusions of Law, and Order of
Discipline issued: Dr Trites’ North Carolina medical license is
suspended indefinitely.
See Consent Orders:
CLARK, Richard Stroebe, MD
NOONAN, Kevin Bernard, MD
WESSEL, Richard Fredrick, Jr, MD
SUMMARY SUSPENSIONS
DIAMOND, Patrick Francis, MD
Location: Evergreen, NC (Columbus Co)
DOB: 5/15/1946
License #: 0098-00042
Specialty: FP (as reported by physician)
Medical Ed: Universidad Autonoma de Tamaulipas, Mexico (1987)
Cause: Upon information that Dr Diamond may be unable to practice
medicine with reasonable skill and safety by reason of illness,
drunkenness, excessive use of alcohol, drugs, chemicals, or any
other type of material or by reason of a physical or mental abnor-mality.
Action: 6/28/1999. Order of Summary Suspension of License issued,
effective 7/01/1999. [Notice of Charges issued 6/28/1999.]
CONSENT ORDERS
AQUILINA, Joseph Nicholas, MD
Location: Saginaw, MI
DOB: 3/07/1935
License #: 0000-38581
Specialty: U (as reported by physician)
Medical Ed: University of Munich, West Germany (1962)
Cause: Dr Aquilina admits and the Board finds that by an order of
11/17/1998, the Wyoming Board of Medicine restricted Dr
Aquilina’s license based on false answers submitted by him on
his license renewal applications in 1997 and 1998.
Action: 5/26/1999. Consent Order executed: Dr Aquilina shall not
practice medicine in North Carolina unless and until the follow-ing
requirements are met and the Board issues an order permit-ting
such practice: should he desire to practice in North
Carolina, he shall first notify the Board and he shall then be
interviewed to determine if he can practice safely and skillfully
and if he possesses the character and integrity expected of North
Carolina physicians; must comply with other conditions.
BORISON, Richard Lewis, MD
Location: Augusta, GA
DOB: 3/04/1950
License #: 0096-00068
Specialty: P/PYG (as reported by physician)
Medical Ed: University of Illinois (1977)
Cause: Dr Borison has been disciplined by the Georgia medical board
and surrendered his Georgia license in October 1998; he execut-ed
a plea agreement, which was accepted by the Superior Court
of Richmond County, Georgia, in October 1998 in which he
admitted he was guilty of one RICO count, 18 counts of Theft
by Taking, 10 counts of Theft of Services, and 7 counts of False
Statements and Representations.
Action: 7/24/1999. Consent Order executed: Dr Borison surrenders his
North Carolina license immediately.
BOSHOLM, Carol Christine, MD
Location: Hendersonville, NC (Henderson Co)
DOB: 10/10/1953
License #: 0096-00151
Specialty: IM (as reported by physician)
Medical Ed: University of Medicine and Dentistry of New Jersey (1989)
Cause: On information that Dr Bosholm has been disciplined by the
New York State Board for Professional Medical Conduct. The
Board finds and she admits that by an Order dated 12/05/1997
New York placed her license on probation for five years based on
false answers submitted by her on her New York license applica-tion.
Action: 6/25/1999. Consent Order executed: the Board reprimands Dr
Bosholm.
Annulment:
Retrospective and prospective cancellation of the
authorization to practice.
Conditions:
A term used for this report to indicate restrictions
or requirements placed on the licensee/license.
Consent Order:
An order of the Board and an agreement between
the Board and the practitioner regarding the
annulment, revocation, or suspension of the
authorization to practice or the conditions and/or
limitations placed on the authorization to practice.
(A method for resolving disputes through infor-mal
procedures.)
Denial:
Final decision denying an application for practice
authorization or a motion/request for reconsider-ation/
modification of a previous Board action.
NA:
Information not available.
NCPHP:
North Carolina Physicians Health Program
RTL:
Resident Training License.
Revocation:
Cancellation of the authorization to practice.
Summary Suspension:
Immediate temporary withdrawal of the autho-rization
to practice pending prompt commence-ment
and determination of further proceedings.
(Ordered when the Board finds the public health,
safety, or welfare requires emergency action.)
Suspension:
Temporary withdrawal of the authorization to
practice.
Temporary/Dated License:
License to practice medicine for a specific period
of time. Often accompanied by conditions con-tained
in a Consent Order. May be issued as an
element of a Board or Consent Order or subse-quent
to the expiration of a previously issued tem-porary
license.
Voluntary Dismissal:
Board action dismissing a contested case.
Voluntary Surrender:
The practitioner’s relinquishing of the authoriza-tion
to practice pending an investigation or in lieu
of disciplinary action.
NORTH CAROLINA MEDICAL BOARD
Board Orders/Consent Orders/Other Board Actions
May, June, July 1999
DEFINITIONS
BROOKS, Michael Lee, MD
Location: Pembroke, NC (Robeson Co)
DOB: 11/24/1950
License #: 0000-28845
Specialty: IM/EM (as reported by physician)
Medical Ed: Bowman Gray School of Medicine (1979)
Cause: From March to May 1998, DAC Health, Inc, acting through Dr
Brooks and various PAs in its employ, rendered medical care to
patients in Raeford, NC, although, under the “corporate practice
doctrine,” a business corporation generally may not practice
medicine. Thus, it engaged in the unauthorized practice of med-icine.
Dr Brooks assisted in this unauthorized practice, permit-ting
DAC Health to bill patients and third-party payors and to
collect payments for all medical services rendered by him; from
these fees, DAC Health paid Dr Brooks salary and kept the
remainder to pay expenses and as profit; by splitting fees with
DAC Health, Dr Brooks engaged in unprofessional conduct. On
March 9, 1998, Robert M. Chavis, PA, began practicing at DAC
Health under Dr Brooks supervision even though the Board did
not approve Mr Chavis’ notification of intent to practice until
March 19; Dr Brooks should have verified Mr Chavis’ status and
should not have supervised a PA who was not approved; in doing
this, Dr Brooks assisted in the unauthorized practice of medicine.
While employed by DAC Health, Dr Brooks dispensed prescrip-tion
drugs for a fee to his patients even though he was not reg-istered
with the Pharmacy Board, thus violating a law involving
the practice of medicine. Dr Brooks failed to countersign 7
charts of patients seen by Mr Chavis within the time required by
rule; he did countersign charts for 2 patients seen at DAC Health
before he came to there and with whose care he had nothing to
do. He states he was unaware his working at DAC Health was
improper and that he quit working for DAC Health when he
became aware of certain problems. He has been cooperative and
has acknowledged his wrongdoing.
Action: 7/22/1999. Consent Order executed: Dr Brooks is reprimand-ed.
CHEN, Jackson Wushoung, MD
Location: Oak Brook, IL
DOB: 11/13/1941
License #: 0000-18357
Specialty: PD/FP (as reported by physician)
Medical Ed: National Taiwan University, ROC (1966)
Cause: Dr Chen executed a Consent Order with the Illinois Department
of Professional Regulation on 4/2/1998 under which he was rep-rimanded
and his license subjected to various probationary
terms. [A copy of the Illinois Consent Order is attached to this
Consent Order and says, among other things, that information
had come to the attention of the Department that he provided
medical services to an entity which was precluded from engaging
in treatment of patients pursuant to Illinois law and that he
allegedly failed to follow proper protocols with regard to hospi-tal
admission of patients, procedures relating to dispensing of
controlled substances and communication with other physicians
involved in patient care. Dr Chen denied the allegations but
accepted the terms and conditions of the Consent Order.
Among other things, his license was placed on probation for one
year and he was fined $10,000.00; his Illinois controlled sub-stance
license was suspended for a period of 90 days.]
Action: 7/8/1999. Consent Order executed: The Board reprimands Dr
Chen; he shall comply in all respects with the Illinois Consent
Order; each calendar year, beginning with 1999, Dr Chen shall
obtain and document to the Board 50 hours of practice-relevant
Category I CME; must comply with other terms and conditions.
CLARK, Richard Stroebe, MD
Location: Memphis, TN
DOB: 10/27/1938
License #: 0000-32670
Specialty: GS/NTR (as reported by physician)
Medical Ed: University of Southern California, Los Angeles (1959)
Cause: Dr Clark admits and the Board finds that he was disciplined by
the Arkansas State Medical Board on 7/18/1998 for pre-signing
blank prescriptions in violation of state and federal laws and that
his Arkansas license was suspended from 6/04/98 to 9/01/1998.
Action: 5/19/1999. Consent Order executed: Dr Clark’s North Carolina
medical license is suspended retroactively from 6/04/1998 to
9/01/1998; to the extent he has not already done so, he shall
comply with the terms of the Order entered by the Arkansas
Board on 7/18/1998 and as that Order may be amended; in
1999, he shall obtain 50 hours of practice-relevant Category I
CME, at least 25 hours of which must be in a public forum; must
comply with other conditions.
CROLAND, David Alan, DO
Location: Little River, SC
DOB: 11/27/1962
License #: 0097-01729
Specialty: FP (as reported by physician)
Medical Ed: Southeastern College of Osteopathic Medicine (1989)
Cause: To amend an existing Consent Order. Dr Croland entered a
Consent Order with the South Carolina board in which he
admitted, among other things, that he furnished fraudulent
information in orders and documents purporting to be prescrip-tions,
which were issued outside the reasonable bounds of a prac-titioner-
patient relationship and for other than legitimate med-ical
purposes, that he furnished fraudulent documents to obtain
and supply his office with fentanyl and other controlled sub-stances
for administration to himself, and that he furnished false
and fraudulent material information to his medical records that
indicated he administered fentanyl and other controlled sub-stances
to patients when he had in fact used them himself; he
later applied for a license in North Carolina and was issued a
license pursuant to a Consent Order on 12/08/1997. He has
asked that his Consent Order be amended so he can prescribe
Schedule IIN controlled substances. It appears his recovery is
going well and he has complied with the terms of his Consent
Order.
Action: 5/11/1999. Consent Order executed: Dr Croland is issued a
license to practice medicine; he shall maintain and abide by a
contract with NCPHP; unless lawfully prescribed for him by
someone else, he shall not consume alcohol, controlled sub-stances,
or any other abusable substance; at the Board’s request,
he shall supply bodily fluids or tissue for screening to determine
if he has consumed alcohol, controlled substances, or any other
abusable substance; he shall not use, dispense, administer, pre-scribe,
or possess, in any manner, Schedule II controlled sub-stances,
Stadol, and Nubain, nor permit these drugs to be in his
office for any purpose; he shall obtain drug and alcohol counsel-ing
from a therapist approved in writing by the president of the
Board; he shall direct his therapist to send quarterly reports to
the Board; he shall attend NA meetings as directed by his thera-pist
and the NCPHP; must comply with other conditions; the
numbered sections of this Consent Order supersede those impos-ing
any continuing obligation in any prior consent order except
those regarding the public nature of such consent orders.
DUNN, Clarence Alvin, Jr, MD
Location: New York, NY
DOB: 12/05/1930
License #: 0000-13790
Specialty: ORS/OTR (as reported by physician)
Medical Ed: University of North Carolina School of Medicine (1963)
Cause: On or about 2/09/1998, the New York Board issued a
Determination and Order by which Dr Dunn’s New York med-ical
license was revoked for misconduct related to practicing
medicine after he was aware his registration had lapsed, allowing
a certification that had been altered to accompany his application
for privileges on two occasions, and for willful failure to register.
Action: 6/29/1999. Consent Order executed: Dr Dunn surrenders his
North Carollina license and the Board accepts that surrender.
ENGLEMAN, James Donald, Jr, MD
Location: Vanceboro, NC (Craven Co)
Greenville, NC (Pitt Co)
DOB: 4/05/1960
License #: 0000-32696
Specialty: FP (as reported by physician)
Medical Ed: University of Louisville (1985)
Cause: To amend an existing Consent Order. Dr Engleman surrendered
his license in June 1995 after relapsing in his use of opiates; on
October 12, 1998, he was issued a temporary license pursuant
to a Consent Order of October 8, 1998; his current Consent
Order says he may not work more than 30 hours a week and Dr
Engleman has asked that limit be removed; the Board has agreed
to his request.
Action: 5/07/1999. Consent Order executed: Dr Engleman is issued a
license to expire on the date shown on the license; he shall prac-tice
only in a setting first approved by the Board’s president; he
shall arrange and pay for a physician monitor who shall be
approved by the Board’s president; the monitor shall regularly
review Dr Engleman’s practice and report to the Board quarter-ly;
unless lawfully prescribed for him by someone else, Dr
Engleman shall refrain from use of all mind and mood altering
substances and all controlled substances and from the use of alco-hol;
he shall notify the Board in writing within 2 weeks of any
No. 3 1999 19
such use, identifying the prescriber and the pharmacy filling the
prescription; at the request of the Board, he shall supply bodily
fluids or tissue for screening to determine if he has consumed any
of these substances; he shall maintain and abide by a contract
with NCPHP; he shall attend AA, NA, and/or Caduceus meet-ings
as recommended by NCPHP; he shall maintain a monthly
log of all controlled substances he prescribes, orders, or adminis-ters
and deliver a copy of that log to the Board each month; he
shall continue psychotherapy with his current therapist or such
other person as may be approved by the Board’s president; he
shall direct his therapist to provide quarterly reports of his
progress to the Board; he shall obtain 50 hours of Category I

Primum Non Nocere
N C M E D I C A L B O A R D
In This Issue of the FORUM
President’s Message:
An Honor and a Privilege..............................1
From the Executive Director:
Dealing with Bureaucracy .............................1
Women Now Outnumber Men in Pharmacy....4
Desmoteric Medicine: A.K.A.,
Correctional Health Care.............................5
Post-Dated Prescriptions Not Permitted ..........6
Wayne W. VonSeggen, PA-C, Elected
President of NCMB.....................................7
Notes on Due Process .....................................8
Notice to Physician Assistants: Provisional
Approval No Longer Available....................9
NCMB Adopts Position Statement
on Laser Surgery .........................................9
Ms Erin Gough Named New Physician
Extender Coordinator..................................9
Hurricane Floyd ............................................10
Don’t Underestimate the Importance
of Chaperones ...........................................11
President’s
Message
From the
Executive
Director
Paul Saperstein Andrew W. Watry
No. 3 1999
Primum Non Nocere
NORTH CAROLINA
MEDICAL BOARD
April 15, 1859
Item Page Item Page
Before I begin my final President’s
Message, I would like to express the Board’s
deep concern about the disaster that has
struck eastern North Carolina. Nothing one
can say can assuage the pain, sorrow, and
loss felt by so many thousands of our fellow
citizens. But there is inspiration and a sense
of pride in the way the people of the whole
state have come together to lend aid of all
kinds and caring hands to those who have
suffered so much. By working together, we
can ensure that the nightmare will end and a
Carolina morning will follow.
I hope you will take a moment to read
the article, Hurricane Floyd, that our execu-tive
director, Mr Watry, has prepared to
address several questions that have come to
us since the hurricane and flooding hit. It
appears on page 10.
An Honor and a Privilege
By the time this article reaches you, my
term of office as president of the North
Carolina Medical Board will be all but over.
It is with a great amount of pride that I can
say that everything in the realm of Board
responsibilities is alive and well.
When asked to serve as the Board’s first
non-physician president approximately one
and a half years ago, I was unsure how I
would be received—not only by the Board
staff, but also by physicians, physician assis-tants,
and nurse practitioners. I quickly
found that any concerns I might have had in
this area were unfounded; my not being a
health care professional led to no opposition
to my role as president. I feel the Board has
added another dimension by allowing itself
to avoid a preconditioned belief that the
head of the Board needs to be a physician.
Serving on the Board over the last few
years, I have seen a lot of changes that have
enhanced our position as one of the top
licensing boards—not only in the state, but
in the nation. Under the leadership of our
new executive director, Mr Andrew Watry,
and his able assistant executive director, Ms
Diane Meelheim, the Board, in its structure
and operation, ranks as one of the outstand-ing
boards in the country. We have been
Dealing with
Bureaucracy
Many people derive a negative connota-tion
from the word bureaucracy. Indeed,
Webster’s gives you a choice between positive
and not so positive definitions. Yet to man-age,
we often need bureaucracy. A bureau-cracy
keeps the office open, bills for services
rendered, responds to consumers, and pro-vides
medical care. The Holy Grail is find-ing
the right balance between meeting your
organizational objectives effectively and
doing so as efficiently as possible.
The North Carolina Medical Board’s orga-nizational
objective is public protection, and
it takes bureaucracy to achieve this objective.
This often causes frustration that we would
like to minimize. In the following para-graphs,
I will offer some helpful hints that
may be useful in reducing some of these
frustrations or avoiding them entirely. These
morsels of information will appear in italics.
In dealing with any bureaucracy, the
object is to get to the end zone. If you are
trying to get to the end zone at Kenan
Stadium from Raleigh, there is a direct route
on Interstate 40 that takes from thirty to
forty-five minutes, depending on whether
you violate the speed limit. There is an infi-nite
number of indirect routes that could
take you through communities such as
Durham, Fayetteville, or Milwaukee and
would take you anywhere from 45 minutes
to several days. Dealing with a medical
licensing board is not unlike this trip to
Kenan Stadium. It could either surprise you
and be a pleasant experience or it could
totally frustrate you when you get caught in
a major traffic jam. There are ways to avoid
the major traffic jams. None of these mech-forum
continued on page 2
continued on page 4
Electronic Distribution to Be Used for
Some Forums, Bimonthly
Board Action Reports,
Immediate Action Notices.........................12
AHCPR and Other Guidelines on
Pain Available ............................................12
North Carolina Physician Demographics:
1979-1998 ................................................13
Recent Changes to PA and NP
Prescribing Rules.......................................14
Review: When Is It Futile? .............................15
Letter to the Editor: Two Questions:
Romantic Relationships, Splitting Fees ..........16
Video Tapes...................................................16
Audio Tape ....................................................17
Board Calendar..............................................17
Board Actions: 5/1999-7/1999......................18
Change of Address Form...............................24
Important Notice: Annual Registration
of Professional Corporations .....................24
DESMOTERIC MEDICINE:
A.K.A., CORRECTIONAL HEALTH CARE
See Page 5
The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum,
including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the
North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are
affiliated. Official statements, policies, positions, or reports of the Board are clearly identified.
We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form
depending on available space. A letter should include the writer’s full name, address, and telephone number.
North Carolina Medical Board
Raleigh, NC forum N C M E D I C A L B O A R D
Vol. IV, No. 3, 1999
Primum NonNocere
NORTH CAROLINA
MEDICAL BOARD
April15, 1859
Primum Non Nocere
2 NCMB Forum
Dealing with Bureaucracy
continued from page 1
we spend on the telephone. The intent is to
be efficient. For calls that branch out of this
system, we spend an average of 78 seconds
per call. In theory, one person could handle
an average of 369 of the 910 calls that come
in each work day, but that is not realistic.
There are two obvious options: doubling the
number of staff available to handle telephone
calls, or providing much more efficient
mechanisms for responding to the bulk of
calls. We are tilting toward the latter. The
idea is to strike a good balance through the
telephone system, getting callers to the end
zone as quickly as possible.
The vast majority of calls are about simple
information, such as a person’s license status,
application status, or registration status. I
will use annual registration as a simple exam-ple.
We have to print one and a half times as
many annual registration forms as we have
licensees. Fully 40% of our licensees call and
ask for a second or even third mailing of
their form. Many of these callers are angry,
implying that the Board never mailed the
registration form in the first place. I can tell
you that this accusation simply does not
make sense. Registration of a license accom-plishes
many purposes, including updating
the Board’s data on the licensee and asking
the licensee probing questions about prob-anisms
are guaranteed, but they can affect
the probability of your success. We want to
assure you that all our Board members and
staff are committed to getting you to the
end zone expeditiously. Following are but
a few suggestions that I hope you find help-ful.
The list is certainly not exhaustive and
we solicit your comments and suggestions.
Getting Licensee Information
Most of us, when we need information
from a bureaucracy, want to call that
bureaucracy immediately, talk to a human
being, and instantly get an answer. If no
one answers the telephone, we assume the
person on the other side is on a smoking
break or an extended lunch. If we get the
dreaded voice messaging system, we almost
immediately assume failure and try to find
the secret mechanisms that have been
placed in that messaging system to punch
out and get a human being.
We at the Board receive an average of
218,580 telephone calls a year, which
breaks down to 18,215 calls per month.
Yes, we have a voice messaging system that
is designed to shorten the amount of time
Paul Saperstein
President
Greensboro
Term expires
October 31, 2001
Wayne W. VonSeggen, PA-C
Vice President
Winston-Salem
Term expires
October 31, 2000
Elizabeth P. Kanof, MD
Secretary-Treasurer
Raleigh
Term expires
October 31, 1999
Kenneth H. Chambers, MD
Charlotte
Term expires
October 31, 2001
John T. Dees, MD
Cary
Term expires
October 31, 2000
John W. Foust, MD
Charlotte
Term expires
October 31, 2001
Hector H. Henry, II, MD
Concord
Term expires
October 31, 1999
Stephen M. Herring, MD
Fayetteville
Term expires
October 31, 2001
Felicia Washington Mauney, JD
Charlotte
Term expires
October 31, 2000
Walter J. Pories, MD
Greenville
Term expires
October 31, 2000
Charles E. Trado, MD
Hickory
Term expires
October 31, 1999
Martha K. Walston
Wilson
Term expires
October 31, 1999
__________
Andrew W. Watry
Executive Director
Helen Diane Meelheim
Assistant Executive Director
Bryant D. Paris, Jr
Executive Director
Emeritus
Publisher
NC Medical Board
Editor
Dale G Breaden
Editorial Assistant
Jennifer L. Deyton
__________
Mailing Address
Forum
NC Medical Board
PO Box 20007
Raleigh, NC 27619
Street Address
1201 Front Street
Raleigh, NC 27609
Telephone
(919) 326-1100
(800) 253-9653
Fax
(919) 326-1130
Web Site:
www.docboard.org/nc
E-Mail:
ncmedbrd@interpath.com
lem areas. However, it is also the principal
source of revenue for the Board. It simply
does not make sense that we would not mail
registration forms. However, as third parties
apply pressure to physicians and other
licensees to keep their licenses current, out of
an abundance of caution a lot of these regis-trants
call and ask for a second mailing of the
form. This means that, at a minimum, we
receive 12,633 calls a year just to request a
registration form, assuming that a licensee
only makes one telephone call. Most of
these calls, in 20/20 hindsight, are unneces-sary
because we mail the second form to the
same address. Of course, we need to make it
easier for licensees to get these forms should
they need them. But here are some sugges-tions
to help licensees avoid problems with
annual registration forms.
(1) Make sure your mailing address on record
with the Board is a good one. Having
your mail come into a large institution
such as a hospital or school increases
chances it won’t get to you.
(2) Don’t be unduly concerned until 15 days
before your birthday. The forms are
mailed 30 to 45 days in advance of your
birth month.
(3) If your forms are handled by others, please
advise them of the importance of your reg-istration
material, which is mailed in spe-cial
envelopes designed not to look like
junk mail.
We are devising alternate mechanisms for
responding more quickly and efficiently to
inquiries about registration and requests for
duplicate registration forms. The first order
of business has been to shift as much infor-mation
as possible to the Web. Please make
a note of our Web address, which we list here and
which we also list in every edition of the Forum:
www.docboard.org/nc. The registration data
we have put on the Web should help mini-mize
the need for a telephone call to the
Board for the same information. We have
also designed a space in the Registration sec-tion
of our site to facilitate e-mail requests
for additional registration forms. (The site
is now a rich source of information, with
details described in earlier Forum editions.
There is a place to obtain a copy of our com-plaint
form. There is a place to check on the
status of a licensee. We want to encourage
you to use our Web site as your first source
for information. If you are able to get a
quick answer to your question or inquiry, we
have been successful.) We are also providing
a voice mailbox so you can leave a message
requesting forms in the event you cannot use
the Web.
Applicants for a License
Other significant telephone queries come
from applicants. We issue about 2,337 new
continued on page 3
No. 3 1999 3
licenses a year. One thing that is common
with many of these applicants is the desire to
start work yesterday. Most applicants allow
the Board sufficient time to process an appli-cation,
never make a query, and get a license
without problems. However, I often receive
calls from applicants who ask for expedited
service, indicating that they have an immedi-ate
need to go to work but the Board is
holding them up. When I check on the sta-tus
of their application, I find that we
received it within the past 48 hours. This is
a totally unrealistic expectation. You don’t get
credentials at a major hospital or at any other
licensing board nearly that fast. Also, we
don’t expedite one applicant at the expense
of others. From a management standpoint,
one thing we see that is frustrating is the
impact these kinds of calls have on applica-tion
processing. Every minute one of our
staff people is talking on the telephone with
an applicant who is asking about the status
of his or her application is time that person
is not processing applications. This is why
we try to bracket our telephone calls about
applications between the hours of 9:00 AM
and noon. We are trying to discourage, to
the extent we can, concerned family and
friends from calling the office about applica-tions.
First, we will not discuss a confiden-tial
application with a third party. Second,
this load hinders our efficiency in turning
around applications more quickly.
We occasionally encounter applicants who
make premature employment commitments.
In some cases, these applicants actually are
put on a payroll before they are licensed. If
these applicants have a malpractice, disci-pline,
or drug and alcohol history, it takes
longer to evaluate them, and we have seen
cases where they have been terminated
because they did not have their licenses
when they thought they would. The best way
to avoid this problem is not to make premature
employment commitments. The minority of
applicants who make such commitments are
not accelerated ahead of and at the expense
of the majority of applicants who have
allowed the Board reasonable time to
process their applications.
The best advice we can give any applicant,
whether applying here or to any other licensing
Dealing with Bureaucracy
continued from page 2
1-800-253-9653
North Carolina
Medical Board
board, is to allow the Board an appropriate
amount of time, obviating the need for telephone
calls. That is the best way to get to the end zone
directly. If you have a target date to start work,
you need to have a completed application in our
office two months earlier—one month cuts it too
close. If you have significant malpractice histo-ry,
board action history, or other such problems,
you need to allow even more time. Also, we
encourage you to take advantage of alternate
mechanisms for dealing with questions about
application status. We have several improve-ments
in place or in development to help
applicants with this information. We pro-vide
a self-addressed postcard with the appli-cation
pack that you can use as a method to
confirm delivery of your application to the
Board. This is designed to minimize tele-phone
calls so we can use available staff more
efficiently to process applications. We are
looking at approaches to posting applicant
information on the Web that will protect
applicant confidentiality. We will let you
know about further developments in this
area.
Complaints
The information above deals with areas
where we are attempting to minimize tele-phone
calls in the interest of efficiency. This
clearly does not apply in the area of com-plaints.
We understand that this is a highly
sensitive area. Many people, when they call
about a complaint, are dealing with a very
sensitive issue: their health care. They do
not want to leave a telephone message. We
would encourage people to use the complaint
form from the Web site to the extent they feel
comfortable doing so. However, you will find
that the complaint component of our voice
messaging system is designed to get you to a
human being, if you need one, in short
order. We understand, for example, if you
feel you have been sexually abused, that you
do not want to leave a voice mail. This is a
very sensitive issue and you may wish to talk
to a compassionate person to relay your
information. We have a very capable com-plaint
department that is equipped to handle
this.
In the spirit of this column, which is
designed around helpful hints, we offer you
the following: try to have your facts assembled;
including the who, what, when, where, and how
of the matter. I recall one patient who sent us
a complaint that, in aggregate, was 20 pages
long. It was about a diagnostic procedure,
but there were pages and pages addressing
the nature of forgiveness, the hands of jus-tice,
and the passage of time. Now, we will
gladly receive extraneous information, but
we need as many factual investigative leads
as you can furnish. Who was the physician?
What did he or she say or do? When, where,
and how many times? Who were the wit-nesses?
Are there other patients you may
know of? Is there any supporting or corrob-orating
material, etc? We are not going to
second guess why you are filing a complaint.
We understand that these are sensitive cases
and some time may have passed since the
matter arose. We will do all in our power to
help you if we can.
Here are two things to bear in mind con-cerning
complaints. (1)The Board is a
quasi-judicial agency. It has to meet a bur-den
of proof in order to substantiate a Board
action, and there has to be a violation of law
within the Board’s jurisdiction. Not every
complaint can be successfully prosecuted.
For example, if you pay $200 to a practi-tioner
for a medical procedure and one of
your friends paid $100 for a similar proce-dure
with another doctor, there is probably
nothing we can do about that. The medical
marketplace is still part of our free market.
However, if that physician billed an insur-ance
company $200 for that same procedure
and that procedure was not performed, there
is something we can do about that. That
activity, if proven, can constitute unprofes-sional
conduct and other violations of the
law. (2)If it is taking the Board a very long
time to finally advise you as to the outcome
of the complaint, there is a good chance that
there is a legal process going on with the
licensee you are complaining about.
Complaints that are investigated and found
to be unprosecuteable are usually opened,
acknowledged to the complainant, investi-gated,
and closed with a closure letter to the
complainant within three months. If it has
been six months or a year or more since you
filed your complaint and you have received
an acknowledgment from the Board but
have not received a notification of final dis-position,
there is a good chance the Board is
actively engaged, which includes a notice to
the licensee of alleged violation, a hearing,
and final disposition. This is a legal process
and, as is the case in all other states, takes
much more time to complete.
Physicians and other health care workers
are often positioned to be aware of signifi-cant
Medical Practice Act violations. The
board has a position statement encouraging
appropriate reporting of incompetence, impair-ment,
and unethical conduct.
Emergency Action
I have described above our system for pro-cessing
contacts with the Board. We do have
mechanisms for branching out of this con-tact
system, particularly the phone messag-ing
system, in cases of emergency or
urgency: entering 0 for operator. We
encourage you to give the messaging system
continued on page 4
4 NCMB Forum
extremely pleased by the fact that Dr George
Barrett, past president of the Board, is presi-dent
elect of the national Federation of State
Medical Boards, recognizing his leadership
skills and the Board’s role in producing dis-tinguished
individuals willing and able to
serve at the highest levels. Our position has
also been enhanced by the fact that both Ms
Meelheim and Mr Watry are leading figures
in the Administrators in Medicine, the
national organization of state medical board
executives.
The Board can be extremely proud of the
quality of the work it has turned out, the
strong administrative staff it has built, the
efficiency of its service in licensing over
30,000 individuals, and the responsive
approach it has developed for dealing with
public complaints and disciplinary issues.
There have been so many changes in the
Board it would be hard to recognize them
all, but I would like to mention a few I feel
have been significant.
l The availability of Dr Jesse Roberts as
medical coordinator for the Board has
been a wonderful asset, allowing Board
members—both physician and non-physician—
to get a broader perspective
of medically-oriented complaints.
An Honor and a Privilege
continued from page 1
a chance for non-urgent inquiries; you may
actually get to the end zone much more
quickly. However, we are equipped to handle a
situation that presents an urgent risk to the pub-lic
health, safety, and welfare, such as a physi-cian
showing up for a shift in a hospital while
intoxicated. You need to punch out of our
messaging system and contact me or any of
our staff with this information so we can
address it immediately. When there is a gen-uine
risk to the public, the Board can con-duct
emergency meetings by teleconference
that can result in summary suspension of a
license, provided there is imminent risk to
the public health, safety and welfare. It takes
very little time to put all of this together.
The imminent risk standard is necessarily
high because, due to the emergency, the
Board is taking action before the licensee has
a hearing. The Board issues approximately
seven summary suspensions a year. In bro-kering
the thousands of contacts we get each
year, these matters rise to the top of the list.
General Information Requests
You may perceive this as bragging, to
which I plead guilty. However, we have one
of the best Public Affairs Departments in the
country. We have staff, at Board direction,
dedicated to making consumer information
available as readily as possible. This is done
because we recognize the importance of
health care and the importance of this infor-mation
to consumers. For example, Board
actions as a result of the disciplinary process
are actively disseminated. We do not in any
way attempt to hold public information
close to the vest; instead, we take deliberate
steps to make it easy to get. The Web page
consolidates access to this information. The
Board allocates substantial resources to this
public information effort, including the
Forum. I might add parenthetically that
these items are funded in North Carolina, as
is the case in almost all other states, entirely
with revenue from licensees, not from tax
revenue or revenue from other sources.
Conclusion
In closing, I hope this material is per-ceived
as intended, as helpful hints to having
satisfactory contacts with the Board when
attempting to get information. We all hate
automated answering systems. About once
a month, I get a message from a physician
who is furious about having to go through
an automated answering system and when I
call that physician back I wind up with an
automated answering system. It is a neces-sary
evil, but if we are using these systems
correctly, we enhance, not detract from, our
ability to respond as efficiently and as effec-tively
as we can.
Most of us, when we hear the word
bureaucracy, infer a negative connotation.
Webster’s, however, provides some options.
Bureaucracy can be either “government
characterized by specialization of functions,
adherence to fixed rules, and a hierarchy of
authority,” or “a system of administration
marked by officialism, red tape, and prolifer-ation.”
The good definition comes before
the bad one. Licensing boards, when fairly
administered, operate on fixed rules. To
allow certain applicants to accelerate their
application at the expense of others would
be chaos. To allow one licensee to be sanc-tioned
and another not for the same viola-tion
would be unfair and discriminatory.
The handling of 218,580 telephone calls,
2,337 applications for licensure, and 31,583
registration forms each year without special-ization
of function and fixed rules would be
total chaos. We aspire to help you get to the
end zone as quickly and efficiently as possi-ble,
taking full advantage of new technology.
It is a work in progress. We invite your com-ments.
u
Dealing with Bureaucracy
continued from page 3
l The increase of talented staff and the
implementation of more effective sys-tems
in the Complaint Department give
us the ability to resolve most complaints
in less than half the time it took only a
few years ago.
It is my belief that staffing enhancements
such as these are responsible for allowing the
Board to do its work on a timely basis.
We at the Board have come to recognize
that our responsibility goes beyond licensure
and discipline. To be vital, that responsibili-ty
must also involve trying to educate both
the public and the medical community as to
what the Board’s function is in the present
managed care environment and how we can
fulfill that function better. In the process, we
hope to build on the rapport we have devel-oped
with the health care professionals and
the public we serve to ensure that the basic
trust that has always been and is so essential
a part of the patient/physician relationship is
never broken or forgotten as changes evolve
in the delivery of health care. I consider
North Carolina to have the best community
of physicians, physician assistants, and nurse
practitioners in the country, and nothing
should be allowed to impinge on their abili-ty
to provide appropriate medical care to the
people of this state.
I have considered it an honor and a privi-lege
to be president of the North Carolina
Medical Board. I have appreciated the
opportunity afforded me by the other mem-bers
of the Board. I know that the next pres-ident,
Wayne VonSeggen, PA-C, of
Winston-Salem, will do an excellent job and
serve the Board with professionalism, dis-tinction,
and honor. u
Women Now
Outnumber Men
in Pharmacy
According to the April issue of the
North Carolina Board of Pharmacy
News, for the first time in North
Carolina’s history, as of January 1999,
the majority of active pharmacists are
women. Board statistics reveal that,
both full-time and part-time, there are
3,227 female pharmacists active in this
state and 3,223 male. These figures
reflect recent pharmacy school gradua-tion
statistics, which in North Carolina
indicate that women are about 70 per-cent
of the graduates.
No. 3 1999 5
continued on page 6
At mid-year
1997, more than 1.7
million people, or
one of every 155
U.S. residents, were
in either jail or
prison. At year-end
1997, one of every
117 males and one of
every 1,852 females
were sentenced pris-oners
under state or
federal criminal jurisdiction.1 Fifteen million
arrests are made annually2 and over ten mil-lion
individuals are released from detention
each year. Approximately two-thirds of
incarcerated individuals are in state and fed-eral
facilities, and the remaining third are in
local, generally short-term stay jails. The
incarcerated popula-tion
cannot and must
not be considered a
small, separate popu-lation
with little rele-vance
to the outside
community.
When offenders
are sentenced to
prison, the state
becomes responsible
for providing them
health care. Desmoteric medicine is the prac-tice
of medicine where the patient popula-tion
is incarcerated or in “bonds.” The term
“desmoteric” originates in the Greek root
desmos, meaning band, bond, or ligament.
Historical Trends
In the 1950s and 60s, health care needs of
the incarcerated were primarily acute injuries
and illnesses consistent with health care
needs of a younger, essentially healthy popu-lation.
Closure of many public mental insti-tutions
in the 1970s led to the incarceration
of many mentally ill for charges stemming
from illness-induced behaviors. In addition,
the National Drug Control Strategy,
announced in 1989, called for mandatory
minimum sentences for drug crimes. By
1995, the impact of the strategy had dra-matically
altered the composition of the
prison inmate population: the number of
inmates in state prisons for drug offenses as
their most serious crime had increased 478%
over the 8.6% reported in 19853. More
recently, mandatory sentencing and longer
prison sentences have contributed to the
increasing trend of older inmates with
chronic diseases: hypertension, coronary
artery disease, chronic obstructive pul-monary
disease, diabetes, hepatitis, HIV, and
others.
The impact of these trends in the North
Carolina prison system has caused our state
prison population to nearly double in 10
years; from approximately 17,000 in 1989
to nearly 33,000 in 1999. Chronic medical
conditions, mental disorders, disease states
associated with drug use, and constant
advances in the treatment of HIV and new
therapies for hepatitis C have created signif-icant
challenges in the provision of health
care to this unique population.
Constitutional and Statutory
Obligations
The Health Services Section of the North
Carolina Department of Correction (DOC)
is mandated to provide inmate medical ser-vices
that meet community standards. Our
constitutional obligation, grounded in the
Eighth Amendment, and the statutory
requirement, GS 135-40.7(5), are best
described in one of the landmark court deci-sions
impacting correctional health care,
Estelle vs Gambel: “...deliberate indifference
to the serious medical needs of prisoners
constitutes the unnecessary and wanton
infliction of pain” in violation of the 8th
Amendment. This requirement and the
North Carolina statutory requirement (GS
135-40.7(5)) charge DOC Health Services
to provide inmates access to quality care pro-vided
by competent health care professionals.
NC DOC Health Services Mission
The North Carolina DOC Health Services
mission is to meet our constitutional and
statutory obligation in a fiscally responsible
manner by:
l viewing correctional facilities as public
health stations that significantly impact
the health status of the larger community;
l managing the care in order to improve
the health status of the inmate and non-inmate
population in order to get best
value for the total tax dollars spent;
l continually asking five questions:
Does the care meet community
standards?
Is the care good medicine?
Is the care appropriate for
the inmate?
Is the care provided good for
the public health?
Have we managed the care in a way
that does not sacrifice quality
and community standards?
Primary Care Driven System
Currently, inmate health care includes
physical, dental, and mental health services
that inmates receive on admission to the
Department of Corrections and throughout
their incarceration. When they enter the sys-tem
through one of the Department’s pro-cessing
centers, inmates receive a number of
health care examinations conducted by
health services staff. Inmates receive a phys-ical
examination, including any needed labo-ratory
tests and X-rays. They receive a visu-al
dental exam and, when determined neces-sary
by a dentist, X-rays and treatment to
correct existing problems. Additionally,
inmates receive a mental health screening,
which includes testing and an interview by
mental health staff to determine their current
psychological functioning level. As a result
of these examinations, health services staff
assigns each inmate a medical classification
status that indicates his or her physical and
mental capability for
institutional and
work assignments.
Inmates who have
been identified as
having a chronic
medical condition,
such as diabetes, asth-ma,
hypertension,
seizures, and/or HIV,
are scheduled for rou-tine
follow-up visits
at intervals not to exceed 90 days once they
reach their assigned institutions.
At each of our major correctional institu-tions,
on-site health care staff provides pri-mary
health care services to inmates. Health
care staff are available or on call 24 hours per
day. Inmates requiring consultations with
specialists or tertiary care not readily avail-able
within the Department are transported
to community facilities for treatment. When
necessary, emergency care is provided by the
closest hospital emergency room.
As in the rest of society, the delivery of
health services in prisons is generally based
on a patient requesting services via the “sick
call” process, describing symptoms, and fol-lowing
the doctor’s instructions. Clearly,
many patients in the “free world” seek health
services in an attempt to obtain secondary
Desmoteric Medicine: A.K.A., Correctional Health Care
Barbara L. Pohlman, MD, MPH
Director, Health Services/Medical Director, Health Services Section
North Carolina Department of Correction’s Division of Prisons
Dr Pohlman
“The incarcerat-ed
population
cannot and must
not be considered
a small, separate
population with
little relevance to
the outside com-munity.”
“ ‘...deliberate
indifference to
the serious med-ical
needs of pris-oners
constitutes
the unnecessary
and wanton
infliction of
pain’ ”
6 NCMB Forum
Desmoteric Medicine
continued from page 5
gain (ie, excused absences from work, dis-ability
benefits, etc). A recent study by the
Florida Office of Program Policy Analysis
and Government Accountability highlighted
how secondary gain is magnified in the
incarcerated population: “In prison, health
services is a primary means by which inmates
can achieve secondary gains, such as avoid-ing
work, relieving boredom, talking to
nurses and other medical staff, or being
transported out of the institution to a com-munity
hospital or another institution.
Inmates may describe false or exaggerated
symptoms in an attempt to achieve sec-ondary
gain.”4 The examples cited in the
Florida study are not uncommon in North
Carolina.
l An inmate who complains of foot pain
may be accurately describing a medical
problem or may simply be trying to
obtain a medical exemption that would
allow him to wear softer shoes than the
Department’s regulation footwear.
l An inmate who visits sick call complain-ing
of lower back pain may be feigning
symptoms in hopes of obtaining an
assignment to a lower rather than an
upper bunk.
l An inmate who declares a mental health
emergency, such as self-injurious behav-ior,
may be seeking to be moved to a
crisis stabilization unit or to a different
institution for some other gain, such as
location, interaction with staff or other
inmates, etc.
Trained nursing staff triage patients for
sick call, assess and treat patients according
to written nursing protocols, and refer
patients to physician extenders and physi-cians
as appropriate. The process is similar
to that of a typical primary care practice.
The North Carolina Correctional
Health Care System
In the last few years, our system has trans-formed
from a provider of prison health ser-vices
to a health care system that provides
services in the correctional environment.
Today, we function as a managed care orga-nization
with expenditures of approximately
$103M. The Health Services Division of
the NC Department of Corrections is a man-aged
care organization with:
l approximately 33,000 covered lives,
l 20,000+ new admissions per year,
l 3 inpatient facilities,
l 84 ambulatory/primary care centers,
l aggressive utilization management,
l aggressive claims management.
Despite population increases and a variety
of factors that tend to increase the cost of
inmate health care, inmate health care costs
in North Carolina have grown at a slower
rate than overall medical costs and at a slow-er
rate than medical care inflation. The
Department’s cost containment efforts have
been effective in reducing costs and include:
l establishing an inmate co-payment sys-tem,
whereby inmates pay $3 for
inmate-initiated, non-emergency visits
or $5 for an inmate-declared medical
emergency;
l establishing a utilization review system
that requires pre-certification and
authorization for off-site specialty con-sults,
outpatient and inpatient services;
l establishing managed care contracts
with community hospitals and special-ists;
l utilizing telemedicine to provide a video
link between inmates and medical spe-cialists;
l monitoring claims from outside
providers for overcharges, incorrect
coding, and contractual reimbursement
compliance issues.
Career Opportunities in Desmoteric
Medicine
Good medicine is good medicine, wherev-er
it is practiced. In a security/custody envi-ronment,
correctional officers have an
important role in the delivery of healthcare:
control of patient flow, transportation of
patients, records,
observations on
behavior, etc. In
addition, the
correctional offi-cer
often has
knowledge of
specific inmate
behaviors and
activities that are
invaluable to the
licensed health
care profession-al,
ie, eating patterns and preferences, med-ication
adherence issues, recreational activi-ties,
etc. Desmoteric medicine is a true
multi-disciplinary team effort that provides
appropriate, medically necessary care for our
patients.
Work with inmate patients in this special
environment is challenging, interesting, and
provides clinical experiences that are not
often encountered in the “free world.” For
the physician or physician extender with the
interest and aptitude to work collaboratively
and cooperatively in a team environment on
challenging clinical issues, desmoteric medi-cine
offers a challenging and satisfying career
opportunity.
“In the last few
years, our system has
transformed from a
provider of prison
health services to a
health care system
that provides services
in the correctional
environment.”
————————————
Notes
1. U.S. Department of Justice. Bureau of Justice
Statistics Bulletin: Prisoners in 1997, August 1998.
2. CDC. Assessment of Sexually Transmitted
Diseases Services in City and County Jails—
United States, 1997. MMWR, 1997, 47:429-31.
3. Bureau of Justice Statistics, Correctional
Populations in the United States, 1996. U.S.
Department of Justice, Office of Justice Programs.
Washington, DC.
4. The Florida Legislature, Office of Program
Policy Analysis and Government Accountability.
Review of Inmate Health Services Within the
Department of Corrections. Report No 96-2. u
Post-Dated
Prescriptions Not
Permitted
Donald Pittman
Field Supervisor, NCMB Investigative
Department
From time to time, Board investiga-tors
discover prescriptions issued for
controlled substances that have been
“post-dated.” The authorizing physi-cian,
for various reasons, will issue two
or more prescriptions to a single patient
for the same medication, record on one
the date the prescription was written
and on the other(s) the date(s) in the
future. According to the Code of
Federal Regulations, Part 1306.05(a),
all prescriptions for controlled sub-stances
shall be dated as of, and signed
on, the day when issued and shall bear
the full name and address of the
patient; the drug name, strength,
dosage form, quantity prescribed, and
directions for use; and the name,
address, and registration number of the
practitioner. A prescription for a con-trolled
substance with a recorded date
other than the day it was issued would
not be in compliance with this federal
regulation.
Whatever the reason a physician may
have for issuing multiple prescriptions
for the same medication to one patient
during a single office visit, there is an
acceptable approach to accomplishing
this. A physician may issue two or
more prescriptions for the same med-ication
on the same day by dating them
all the day they are issued and writing
“do not fill until (future date[s] that
medication may be dispensed)” on the
one(s) to be filled at a later time.
No. 3 1999 7
Wayne W. VonSeggen, PA-C, of Winston-Salem,
Elected President of North
Carolina Medical Board: First Physician
Assistant to Hold The Post
At its regular meeting in July, the North
Carolina Medical Board elected its officers
for the next year. They will take office on
November 1, 1999, and serve until October
31, 2000.
Wayne W. VonSeggen, PA-C,
New NCMB President
Wayne W. VonSeggen, PA-C, of
Winston-Salem, will
assume the post
of president of
the North Carolina
Medical Board on
November 1, suc-ceeding
Mr Paul
Saperstein, of Greens-boro,
in that posi-tion.
Mr VonSeggen
is the first physician
assistant to be chosen
president of the Board. He has served as
vice president of the Board over the past
year.
Mr VonSeggen, a native of Iowa, has been
a physician assistant for over 22 years and
currently works with Dr George Franck at
the Employee Health Center at Wake Forest
University Baptist Medical Center in
Winston-Salem. He received his BA degree
in chemistry and zoology from Olivet
Nazarene University in Illinois, with gradu-ate
work in anatomy at the University of
Iowa, and completed the Physician Assistant
Program at Bowman Gray School of
Medicine of Wake Forest University. He is a
fellow member of the American Academy of
Physician Assistants, a charter member of
the North Carolina Academy of Physician
Assistants, and an associate member of the
North Carolina Medical Society, participat-ing
with the Bioethics Committee.
Mr VonSeggen has served as president of
the North Carolina Academy of Physician
Assistants, has coauthored the results of
three state-wide surveys of the PA profes-sion,
and plays an active role in several pro-fessional
organizations. He was named to
the Board in 1994 and has acted as chair of
the PA Committee, nominating members of
the PA Advisory Committee to the Board.
He has been a member of several other key
Board committees, including the Licensing,
Investigations, EMS, and Scope of Practice
Committees.
Mr VonSeggen
Elizabeth P. Kanof, MD, Vice
President
Also on November 1, Elizabeth P.
Kanof, MD, of
Raleigh, will be-come
vice president
of the North
Carolina Medical
Board, replacing
Mr VonSeggen. Dr
Kanof was appoint-ed
to the Board in
1996 and served as
secretary-treasurer
over the past year.
Dr Kanof, a native of New York, received
her BA from Mount Holyoke College and
her MD from New York University. She did
an internship at Kings County Hospital
Center and residencies in dermatology at
New York University-Bellevue Medical
Center and Duke University Medical Center.
She is a fellow of the American Academy of
Dermatology and a diplomate of the
American Board of Dermatology. She holds
appointments as assistant clinical professor
of dermatology at the Duke University
School of Medicine and as adjunct clinical
professor of dermatology at the University
of North Carolina School of Medicine.
Very active in organized medicine, Dr
Kanof served as president of the Wake
County Medical Society in 1984 and of the
North Carolina Medical Society in 1994.
She has served on or chaired numerous
Medical Society committees and currently
serves as a Medical Society delegate to the
American Medical Association. Over the
years, she has also been a participant in a
wide range of community and charitable
groups.
She has published several articles and, in
1996, was coauthor of “Overcoming
Barriers to Physician Involvement in
Identifying and Referring Victims of
Domestic Violence,” published in the
Annals of Emergency Medicine.
Dr Kanof has served on the Board’s
Malpractice, Physician Assistant, Physicians
Health Program, and Liaison Committees,
and has been chair of its Complaints, Scope
of Practice, and Alternative Medicine
Committees.
Dr Kanof
Walter J. Pories, MD, Secretary-
Treasurer
Walter J. Pories, MD, of Greenville, will
take office as the
Board’s new secre-tary-
treasurer on
November 1, replac-ing
Dr Kanof. A
native of Germany,
Dr Pories is profes-sor
of surgery
and biochemistry at
the East Carolina
University School of
Medicine. He is also
a clinical professor of surgery at the
Uniformed Services University of Health
Sciences. He received his BA at Wesleyan
University, Middletown, Connecticut, and
his MD with honors from the University of
Rochester School of Medicine and Dentistry.
His postgraduate study included an intern-ship
at Strong Memorial Hospital of the
University of Rochester; a part-time fellow-ship
at the Centre du Cancer of the
Universite de Nancy, France; a graduate
research fellowship in biochemistry at the
University of Rochester; and a residency in
general and thoracic surgery at Strong
Memorial Hospital. He is certified by the
American Board of Surgery and the
American Board of Thoracic Surgery. He
was appointed to the North Carolina
Medical Board in 1997.
Frequently honored for his work as a sur-geon
and teacher, Dr Pories is a past gover-nor
of the American College of Surgeons
and has served as president of the North
Carolina Chapter of the American College of
Surgeons, the North Carolina Surgical
Association, the Eastern Carolina Health
Organization, Hospice of Greenville, and
the Association of Program Directors in
Surgery. Active on a large number of pro-fessional
boards and committees, he is also
the author/coauthor of 47 book chapters, 7
books, and over 250 medical articles dealing
primarily with the metabolism of trace ele-ments,
diabetes, and surgical education. He
has also been involved in the making of four
educational films.
Dr Pories is a retired colonel of the U.S.
Army Reserves. He has published over 50
cartoons and is a talented artist. u
Dr Pories
8 NCMB Forum
continued on page 9
Why Give Due Process?
Deciding whether to deny an applicant a
license and considering whether to take one
away are among the most difficult and
wrenching decisions the North Carolina
Medical Board must make. The Board nei-ther
relishes these duties nor shrinks from
them. Usually, a person appearing before
the Board has invested a
lifetime to reach profes-sional
goals. Society,
likewise, has a consider-able
stake: its own
investment in the per-son’s
education and
training and its need for
protection from the
occasional unscrupulous, incompetent, or
impaired medical professional. Because so
much is at stake, emotions tend to run high.
To help ensure that these decisions are
carefully and fairly made, the Board must
follow certain law and rules, commonly
referred to as “due process” after the lan-guage
of the Fifth Amendment to the U.S.
Constitution, which states that no one shall
“be deprived of life, liberty, or property,
without due process of law.” The North
Carolina Constitution, in its “law of the
land” clause contains a very similar idea.
Basically, the concept is that a state (acting in
this case through a medical board) must use
due process before depriving a person of a
property right (in this case a license or other
approval to practice). The question, then, is,
What process is due a person in these cir-cumstances?
What Process Is Due?
It surprises some that the Board’s power is
not absolute on such matters. The constitu-tions
establish a minimum, the fundamentals
of which, generally speaking, include having
notice that the matter is being considered
and an opportunity to be heard. Statutes
passed by the General Assembly, and to
some extent by Congress, provide more,
governing the reasons the Board may act,
the procedures it must follow, and the
actions it may take. While few Board deci-sions
are ever disturbed, its actions are sub-ject
to review by the courts.
On What May the Board Act?
Statutes (and rules for physician assistants,
nurse practitioners, and emergency medical
technicians) set forth the reasons the Board
may deny a license or take one away. About
20 reasons are given. Many are fairly obvi-ous:
unethical or unprofessional conduct,
incompetence, and being impaired. Others
are less so, for example, not paying child
support. Some of these are written in broad
and general terms, allowing the Board to
enforce professional standards within the
common understanding of those in practice.
Others are fairly specific, for example, failure
to register. Only the one requiring continu-ing
medical education explicitly authorizes
the Board to make rules outlining its con-tours.
In sum, the Board has broad power
to act, but unless one of these reasons in the
statutes or rules applies, the Board’s hands
are tied. As an example, without more to act
on, conviction of a misdemeanor is not nec-essarily
grounds for discipline.
What Procedures Must the Board Use?
In its investigations
Statutes set forth the procedures the
Board must use. It is given broad but not
unlimited powers in investigating its cases.
For example, the Board can obtain patient
records without obtaining a court order (as
is usually required in court cases), but it does
not have the power to search without con-sent
(as in a search warrant) nor does it make
arrests.
In its hearings
Proceedings before the Board are much
like civil cases in court. Statutes govern how
the Board begins a case, who will hear the
case, and where the case will be heard.
Statutes govern the discovery process by
which information is exchanged in the case,
what portions of the proceeding and docu-ments
are public, and what evidence is
admissible. Statutes give the Board’s oppo-nents
rights to appear personally and with a
lawyer, to cross examine witnesses, to pre-sent
evidence, to subpoena witnesses, and to
make arguments. Statutes give the presiding
officer judge-like powers and require the
Board to act somewhat like a jury. Statutes
govern the right to appeal a Board decision,
which is fairly similar to appeals in civil
cases, going through the courts to ensure the
Board has acted lawfully, that its decisions
are supported by the evidence, and that it
has not acted arbitrarily or capriciously.
What May the Board Do?
Statutes govern the actions the Board may
take, giving it the power to deny an applica-tion,
annul, revoke, suspend, or limit a
license. Under limited circumstances, the
Board may order restitution. It may also
stay its actions or restore a license on condi-tions.
In emergencies, the Board may sus-pend
or summarily suspend a license pend-ing
the outcome of a case, but it must
promptly begin and decide the case after
doing so. It does not have the authority to
do other things, such as fine or imprison.
Can the Process Be Abbreviated?
Sometimes hearings before the Board are
conducted elaborately, using all the proce-dures
set out above in all their detail.
Usually, considerable effort is applied to nar-rowing
the issues to those truly in dispute,
and, with the consent of the Board and the
affected person, the unnecessary procedures
can be discarded. Put another way, the
process is designed not only for fairness but
also for efficiency.
Consent Orders
At any point in the process, from before
charges are brought to after the hearing is
held, the Board and the affected person can
agree to a resolution of the matter. Public
policy in North Carolina encourages the
Board, though the law does not require it, to
attempt resolution of cases through informal
means. When an accord can be reached, the
law expressly permits an agreed disposition
of the matter.
The usual mechanism is a Consent Order.
Consent Orders are both orders of the Board
and agreements between the Board and the
affected person. Consent Orders typically
begin by identifying
the affected person
and setting forth the
areas of concern to
be addressed. Next,
Consent Orders
recite the obligations
of the Board and the
affected person, for
example, the person’s
license status and the
conditions on which the continuation of that
status depend. Consent Orders contain an
enforcement mechanism, usually that a fail-ure
to abide by the Consent Order will con-stitute
grounds for the Board to act, even if
the law would not otherwise give the Board
such power.
How Much of This Is Public?
By statute, the Board’s licensing and
investigative information is not public,
unless and until it is used in a case before the
Board. Also by statute, once the Board
Notes on Due Process
James A. Wilson, JD
Director, NCMB Legal Department
“No one shall
‘be deprived of
life, liberty, or
property, with-out
due process
of law.’ ”
“Because the
Board’s decisions
can end a career,
it is important
they be made
carefully and
deliberately.”
No. 3 1999 9
Notes on Due Process
continued from page 8
NCMB Adopts
Position Statement on
Laser Surgery
At its meeting in July, the North Carolina
Medical Board adopted a positon statement
on laser surgery. It appears below.
The principles of professionalism and per-formance
expressed in the position state-ments
of the North Carolina Medical Board
apply to all persons licensed and/or
approved by the Board to render medical
care at any level. (The words “physician”
and “doctor” as used in the position state-ments
of the Board refer to persons who are
MDs or DOs licensed to practice medicine
and surgery in North Carolina.)
LASER SURGERY
It is the position of the North Carolina
Medical Board that the revision, destruction,
incision, or other structural alteration of
human tissue using laser technology is
surgery.* Laser surgery should be per-formed
only by individuals licensed to prac-tice
medicine and surgery or by those cate-gories
of practitioners currently licensed by
this state to perform surgical services.
Licensees should use only devices
approved by the U.S. Food and Drug
Administration unless functioning under
protocols approved by institutional review
boards. As with all new procedures, it is the
licensee’s responsibility to obtain adequate
training and to make documentation of this
training available to the North Carolina
Medical Board on request.
Lasers are employed in certain hair-removal
procedures, as are various devices
that (1) manipulate and/or pulse light caus-ing
it to penetrate human tissue and (2) are
classified as “prescription” by the U.S. Food
and Drug Administration. Hair-removal
procedures using such technologies should
be performed only by a physician or by a
licensed practitioner with appropriate med-ical
training functioning under the supervi-sion,
preferably on-site, of a physician who
bears responsibility for those procedures.
*Definition of surgery as adopted by the NCMB,
November 1998:
Surgery, which involves the revision, destruc-tion,
incision, or structural alteration of
human tissue performed using a variety of
methods and instruments, is a discipline that
includes the operative and non-operative
care of individuals in need of such interven-tion,
and demands pre-operative assessment,
judgment, technical skills, post-operative
management, and follow up. u
(Adopted July 1999)
begins a case, much becomes public. The
Notice of Charges is public, as is any
response to it. The hearings themselves are
open to the public, and the things admitted
into evidence and the transcripts of testimo-ny
are public. Though the Board’s delibera-tions
are closed, its final written decisions are
public. Appeals of Board decisions are pub-lic.
Consent Orders are public. However,
by statute, the Board will protect the identi-ty
of patients who do not consent otherwise.
Conclusion
Contrary, perhaps, to the impression of
some, the Board is not set at large to “make
things right.” It can act only on the grounds
set forth in the law, using only the proce-dures
and taking only the actions established
by law.
Obviously, no system can ensure perfect
decisions, and because the Board’s decisions
can end a career, it is important they be made
carefully and deliberately. The procedures
outlined here are designed to guide the
Board to fair and just consideration of each
case it addresses.
Notice to Physician
Assistants:
Provisional
Approval No
Longer Available
The North Carolina Medical Board
wants you to be aware that provisional
approval is no longer available for
physician assistants. (Provisional
approval is not to be confused with a
temporary license, which is the type of
license a PA receives before taking or
passing the examination of the
NCCPA.) Temporary and full license
numbers will be assigned once each
month during the regularly scheduled
meetings of the Board. This approach
is required because there is no provi-sion
in the statutes of North Carolina
for staff approval of a license applica-tion;
it must be voted on by the Board.
An applicant can expect to get her or
his license number in writing within
seven business days following the last
day of the Board meeting at which the
application is approved. Application
deadlines are printed in each issue of
the Forum.
Ms Gough
Ms Erin Gough
Named New
Physician Extender
Coordinator
Ms Erin Gough is the new
Physician Extender Coordinator for
the Licensing Department of the
North Carolina Medical Board. She
succeeds Ms Terresa Wrenn.
Ms Gough is primarily responsible
for processing physician assistant
applications and intent to practice
applications. Her duties include
preparing PA materials for review by
the Board and staffing Nurse
Practitioner, Physician Assistant, and
Midwifery Committee meetings. She
also assigns PA license numbers and is
authorized to make written and verbal
verifications of PA licenses and NP
practitioner approvals.
She is available to answer telephone
inquiries regarding application
requests, application status, verifica-tions,
and rules applicable to PAs and
NPs on any weekday from 2:30 to
5:00 PM. She may be reached at
(800) 253-9653, extension 233, or
(919) 326-1100, extension 233.
Mr James Campbell continues to
handle NP applications (initial and
subsequent). Questions about these
may be directed to him on any week-day
from 2:30 to 5:00 PM. He may
be reached at (800) 253-9653, exten-sion
250, or (919) 326-1100, exten-sion
250.
The NCMB’s Web site features a
useful description of the Licensing
Department and now offers the PA
Intent To Practice Form. The rules
and the Medical Practice Act may also
be downloaded from the site. The
address is www.docboard.org/nc. u
10 NCMB Forum
Hurricane Floyd and its accompanying
deluge of rain presented a disaster of
unprecedented proportions for North
Carolina—particularly the eastern portion
of our state. The problems its aftermath
presents our licensing system are pale by
comparison with the misery and suffering
of thousands of our citizens. However, it
did affect our licensing system and we
have had serious questions about licensing
issues. In an effort to be helpful, we offer
the following suggestions that may be of
benefit to those adversely affected.
Medical Records
As you know, the Board has a position
statement on medical records. This posi-tion
statement, along with the rules and
laws governing the practice of medicine,
can be found at our Web site at
www.docboard.org/nc. Several physicians
had their offices flooded by Floyd and did
not have enough time to salvage their
medical records, which are now so much
mush.
We have received questions about what
would happen if, in the future, one of
these physicians was called on to produce
a patient chart that had been destroyed by
flood waters? In that regard, we want you
to know that one of the reasons this state
and all other states have medical boards is
to provide a group of reasonable, respon-sible
board members, fellow citizens, to
apply prudent judgement on public pro-tection
issues. The North Carolina
Medical Board is among the most reason-able
and prudent you will find anywhere
in the country. You can read between the
lines of the Board’s position statements
the public policies that are the foundation
for those statements. The Board is
attempting to ensure that there is continu-ity
of patient care, that patients have
access to their medical records, and that
medical records are appropriately docu-mented
so they are useful instruments in
managing patient care. That being said, if
an issue presents itself one, two, or five
years from now where a medical record is
requested to resolve a patient complaint or
similar issue, you can expect the Board to
be reasonable if the physician’s office or
record storage area was ravaged by the
floods accompanying Floyd in September
1999. It may simply be impossible for
that physician to produce a good medical
record because of the flood damage.
We have suggested to those who have
asked that they should apply the same prin-ciples
to rebuilding badly damaged or
destroyed records as they would to triaging
patients. That is, they should identify the
patients with the most urgent needs, includ-ing
those requiring routine prescriptions,
and try to rebuild those records first based
on memory and any other sources available.
We have also suggested placing a note in
each patient’s file stating that certain records
were not recoverable due to flood damage
and the basis on which a reasonable, good
faith effort was made to restore such records.
This document itself will serve as part of the
medical record to explain the absence of crit-ical
documentation. (We recognize that, in
some instances, it may not be possible or
reasonable to attempt the rebuilding of a
particular record.)
In summary, a licensee can expect the
Board to be reasonable in future issues when
original and complete patient records cannot
be produced as a result of Floyd’s devasta-tion.
The Board simply expects licensees to
make reasonable efforts to restore those
records, where appropriate, consistent with
the public policy that governs the Board’s
actions.
Volunteerism
Balancing the negative effects of this
tragedy are the significant volunteer efforts
to help people recover. There is considerable
volunteerism occurring in the medical com-munity.
We have received the inevitable
licensing question as a result. This state, as
is the case in most other states, has an emer-gency
plan whereby the Governor can take
emergency action to relax licensing statutes
where appropriate. Exercising this authority
in the case of Floyd was not necessary.
Licensing statutes exist for a good reason:
public protection. In a disaster such as North
Carolina has suffered, the public needs to be
protected from fleecing by price-gouging,
shoddy contractors, and others who might
take advantage of such a situation. Medicine
is no exception. There are over 5,000 physi-cians
disciplined in this country each year for
rather significant violations of public trust.
There are many thousands more people in
this country who were trained as physicians
but who have not demonstrated the mini-mum
competencies required by the licensing
system, such as passing a licensing exam,
completing appropriate post-graduate train-ing,
and passing credential checks involving
criminal history, action in other states, mal-practice
history, etc.
There is significant volunteerism by
appropriately licensed and credentialed
physicians and, frankly, no need to com-pound
this disaster by exposing our citi-zens
to medical personnel who have not
been appropriately credentialed. The
North Carolina Medical Society has risen
to the task of coordinating volunteerism
for this critical situation from the large
pool of physicians who hold a North
Carolina license.
Any physician who would like to put
his or her name on a list of volunteers to
help in future emergencies should write or
telephone the North Carolina Medical
Society: 222 North Person Street,
Raleigh, NC 27601; (919) 833-3836.
Immunization
There is an increased need for immu-nizations
due to the ravages of Floyd.
Fortunately, this state has an effective
approach to making immunizations avail-able
to the public at times like this. They
are available through the health depart-ments
and from a variety of authorized
health care providers.
Clearly, immunizations should be given
only by those qualified and authorized to
do so. A small percentage of people have
reactions to immunizations that require
appropriate medical treatment. There are
other issues, such as the handling of hypo-dermic
needles, that require appropriate
training to prevent the spread of infection
and viruses such as HIV and hepatitis.
Immunizations require appropriate med-ical
control, which means a prescription
from an authorized practitioner and an
appropriate protocol for delegation of
administration to other practitioners,
including appropriate management of the
serum and the hypodermic needles. You
do not want serum that is out of date or
has been improperly stored or needles that
may transmit infection.
In short, there is a good reason for the
protections afforded by your state licens-ing
system, including the licensing or
approval of physicians, pharmacists,
physician assistants, advanced practice
nurses, nurses, paramedics, and other
health practitioners involved in this recov-ery
effort. Any waiving of the require-ments
would only compound risks for
those already suffering as a result of this
disaster. u
Hurricane Floyd
Andrew W. Watry
Executive Director, NCMB
No. 3 1999 11
The relationship between a physician and
a patient is based on trust and mutual confi-dence.
The North Carolina Medical Board
identifies multiple elements that are neces-sary
for maintaining a patient’s trust. (See
the NCMB’s position statement: The
Physician-Patient Relationship.) Among the
elements identified are respect for a patient’s
autonomy, the assurance of confidentiality,
and adequate communication between
physician and patient. During the course of
the physician-patient relationship, it is very
likely that a physical examination, which
includes deliberate examination and touch-ing
of the patient by the health care provider,
will occur.
Reassuring the Patient, Protecting
the Physician
Chaperones have long been used for gyne-cologic
examina-tions
and proce-dures.
The third
party serves not
only to provide
reassurance to the
patient and to assist
the physician, but
also to protect the
physician against
unfounded accusa-tions
of inappropri-ate
behavior.
Allegations that health care providers have
committed sexual improprieties against
patients are infrequent. Despite their rarity,
allegations of sexual misconduct have been
brought against physicians and dentists prac-ticing
in such diverse fields as family prac-tice,
psychiatry, anesthesiology, general den-tistry,
and endodontics. When allegations of
sexual improprieties are made, the accused
faces the devastating aftermath of emotional
turmoil, damage to professional credibility,
possible criminal charges, and costly civil
actions.
How are health care providers using chap-erones?
Studies reflect that the use of chap-erones
during female genital examination
varies by sex of the
health care provider.
One study of family
physicians noted
that 79.4% of male
physicians and
31.9% of female
physicians surveyed
used chaperones
during female geni-tal
examinations.
The same study
noted the rate of chaperone use during male
genital examination was 1.4% for male
physicians and 14.4% for female physicians.1
Another study of primary care physicians
reported higher chaperone use during female
genital examination: 96.9% for male physi-cians
and 64.0% for female physicians.2
The study of chaperone use has now
expanded to include health care providers
who care for patients whose mental status
may be altered by the use of sedatives, hyp-notics,
anxiolytics, or analgesics, or by recov-ery
from anesthesia. A patient awakening
from anesthesia may misinterpret a touch or
even imagine a sexual advance that did not
happen.
Many dentists who use sedation during
procedures have made having a third party
in the room a standard operating procedure.
Anesthesiologists are usually providing anes-thesia
care in the presence of a room full of
their peers. However, sexual assaults have
occurred in pre-operative holding areas and
recovery rooms. In a California case, an
anesthesiologist drew the curtains around
the stretchers of several female patients in
order to conceal his assaults.3
What Can You Do?
What can you do as a health care provider
to protect yourself against unfounded accu-sations
of sexual misconduct? The North
Carolina Medical Board’s current position
statement on the subject, Guidelines for
Avoiding Misunderstandings During
Physical Examinations, states that:
Whatever the sex of the patient, a third
party should be readily available at all
times during a physical examination,
and it is advisable that a third party be
present when the physician performs an
examination of the breast(s), genitalia,
or rectum. When appropriate or when
requested by the patient, the physician
should have a third party present
throughout the examination or at any
given point during the examination.
Current risk management recommenda-tions
from Medical Mutual advise the use of
a chaperone for all physicians conducting
any type of physical examination in which
removal of clothing is involved. The pres-ence
of a chaperone is strongly recommended
if a physician and patient are of different
genders and an examination involves cloth-ing
removal. It should be noted that these
recommendations apply to patients of all age
groups.
As stated previously, chaperones have
been most frequently used during female
genital examinations. In consideration of
the prevailing liti-gious
climate, chap-erones
should be
considered for male
genital examinations.
As a physician, the
issue of a chaperoned
examination should
be addressed with
the patient prior to
the examination.
Should a patient
refuse a chaperone,
this refusal should be documented and ini-tialed
by the patient.
Because physicians are continually asked
to “do more with less,” your practice may
view the use of chaperones as a poor use of
resources. The use of chaperones does
require staff coordination and may result in
increased time between patient examina-tions.
However, the cost of being falsely
accused of sexual misconduct in a victim-ori-ented,
tabloid-saturated society cannot be
underestimated.
————————————
Notes
1. Gilchrist, Gillanders, Gemmel: Chaperoning
Practices of Ohio Family Physicians. Family
Medicine, July 1992; Vol 24, No 5: 386-389.
2. Renfroe, Replogle: Chaperone Use in Primary
Care. Family Medicine, March-April 1991; Vol 23,
No 3: 231-233.
3. Anesthesia Malpractice Prevention. April 1996;
Vol 1, No 4: 25-27.
————————————
Reprinted in edited form from Medical Mutual’s
quarterly MedNotes, Summer 1999. u
Don’t Underestimate the Importance of Chaperones
Naomi M. Tsujimura, RN, CCRN
Claims Department, Medical Mutual Insurance Company of North Carolina
Ms Tsujimura
“One study noted
79.4% of male
physicians and
31.9% of female
physicians sur-veyed
used chap-erones
during
female genital
examinations.”
“A chaperone is
strongly recom-mended
if a
physician and
patient are of
different genders
and an examina-tion
involves
clothing
removal.”
“Despite their
rarity, allegations
of sexual miscon-duct
have been
brought against
physicians and
dentists practicing
in diverse
fields ”
12 NCMB Forum
Forum
Beginning in 2000, the Forum will be
available to commercial organizations
and a number of other groups and indi-viduals
only via the Internet. The North
Carolina Medical Board’s Web site
(www.docboard.org/nc) has been presenting
the Forum, exactly as it appears in its print-ed
form, since late 1998. To access it only
requires the Adobe Acrobat Reader, which
can be downloaded free at www.adobe.com,
and the Board’s Web site provides a quick
link to the Adobe site. Using the Adobe
Acrobat Reader, the Forum can be easily
read on screen and readily printed out.
This has been the general public’s major
access to the Forum for the past year.
(Should you have trouble with this
process, please contact Jennifer Deyton of
the Board’s Public Affairs Department.
She can be reached by telephone at 1-919-
326-1100, ext 271, or by e-mail at pub-lic.
affairs@ncmedboard.org.)
We find this approach an effective way
of dealing with the constantly growing
demand for the Forum on the part of a
very wide spectrum of readers. From a
practical point of view, only so many
copies of the Forum can be published and
mailed each quarter. However, this elec-tronic
system allows those who have an
interest in the Forum, the diverse articles
and the data it presents, to receive it if
they have access to the Internet in home,
office, or library. Therefore, should you
not receive the first number of the Forum
for 2000 by early April 2000, check the
Internet. The new number will be there
or a notice will be posted telling you when
to expect its appearance.
Bimonthly Board Action Reports
and Immediate Action Notices
For almost five years, the North
Carolina Medical Board has been sending
a Bimonthly Board Action Report, listing
all its public actions relating to physicians,
physician assistants, and nurse practition-ers,
to hospitals, medical groups, and the
news media. It has also issued Immediate
Action Notices for actions involving
annulments, revocations, suspensions,
summary suspensions, and license surren-ders.
These notices go out as soon as the
AHCPR and Other
Guidelines on Pain
Available
Among its many other activities over the
past decade, the Agency for Health Care
Policy and Research (AHCPR) of the U.S.
Public Health Service has facilitated devel-opment
of clinical practice guidelines on a
variety of topics. Three of these, published
from 1992 to 1995, deal with the manage-ment
of pain. They include Acute Pain
Management: Operative or Medical Procedures
and Trauma; Management of Cancer Pain;
and Acute Low Back Problems in Adults.
Several versions of each guideline are
available. The “Clinical Practice Guideline”
presents recommendations for health care
providers with brief supporting information,
tables and figures, and pertinent references.
“The Quick Reference Guide for Clinicians”
is a distilled version of the “Clinical Practice
Guideline,” with summary points for ready
reference on a day-to-day basis. “The
Consumer Version (or Patient Guide),”
available in English and Spanish, is an infor-mation
booklet for the general public to
increase patient knowledge and involvement
in health care decision making.
To order single copies of these (or any)
AHCPR guideline publications or to obtain
further information, call the AHCPR
Publications Clearinghouse toll-free at 800-
358-9295 or write to: AHCPR Publications
Clearinghouse, PO Box 8547, Silver Spring,
MD 20907.
Also available is the fourth edition of
Principles of Analgesic Use in the Treatment
of Acute Pain and Cancer Pain (1999)
from the American Pain Society, 4700
West Lake Avenue, Glenview, Illinois
60025-1485. The APS’ Web site address is
http://www.ampainsoc.org/.
The World Health Organization has sever-al
titles dealing with the relief of cancer pain
and palliative care. These include the second
edition of Cancer Pain Relief with a Guide to
Opioid Availability (1996), Cancer Pain Relief
and Palliative Care in Children (1998), and
Symptom Relief in Terminal Illness (1998).
For further information on these publica-tions,
contact Distribution and Sales, World
Health Organization, 1211 Geneva 27,
Switzerland. u
Electronic Distribution to Be Used for Some
Forums, Bimonthly Board Action Reports,
Immediate Action Notices
actions occur and make the information
available at once, not delaying it until the
next bimonthly release. Due to cost con-straints,
the Board has focused over these
years on sending these materials only into
those counties in which the involved
physicians, PAs, or NPs actually practiced
and to relevant state agencies. As with
the Forum, which reprints the reports
for statewide circulation, the Bimonthly
Board Action Reports and the Imme-diate
Action Notices have been appear-ing
on the Board’s Web site
(www.docboard.org/nc) since 1998. In fact,
we are now posting a full year’s worth of
the bimonthly reports, allowing the Web
user to go back over the year’s activity.
Anyone with access to the Internet can
easily review these reports and notices: the
public, hospitals, medical groups, the
media, other state agencies, other states,
etc.
We want all the state’s hospitals, med-ical
groups, news media, and relevant
organizations to know that we would like
to notify them by e-mail each time a new
report or notice has been posted. This
notification system would ensure quick
statewide distribution of the material, not
limited simply to the counties in which
the involved practitioners may practice.
Any hospital, medical group, newspaper
or journal, television or radio station, or
interested organization that makes its e-mail
address available to us in writing or
by e-mail will be made a part of this noti-fication
system. That will make it unnec-essary
for us to mail a printed copy of the
particular Bimonthly Board Action
Report or Immediate Action Notice to
that institution, organization, or person,
saving time and costs on both sides.
If you wish to participate in this system,
please send the appropriate e-mail address,
along with your name or the name of the
responsible person, and the name and
address of your institution, organization,
or other affiliation, to: Jennifer Deyton,
Public Affairs Department, North
Carolina Medical Board, PO Box 20007,
Raleigh, NC 27619; or e-mail the same
information to Ms Deyton at
public.affairs@ncmedboard.org. u
North Carolina Medical Board
E-Mail:
ncmedbrd@interpath.com
No. 3 1999 13
North Carolina Physician Demographics: 1979-1998
Michael J. Pirani, PhD, Director, Health Professions Data System, Sheps Center for Health Services Research, UNC, Chapel Hill
Thomas C. Ricketts, PhD, MPH, Deputy Director, Sheps Center for Health Services Research, UNC, Chapel Hill - Director, Rural Health Research Program.
The demographic structure of North
Carolina’s physician work force has undergone
significant changes over the last 20 years. The
proportion of women physicians is increasing
every year, and the age structure of the state’s
physicians is also changing. Physician demo-graphic
characteristics are not homogenous
across the state, as physicians in rural counties
are older on average and there are proportion-ally
fewer rural women physicians than urban.
This report is another in a series of analyses
made possible by 20 years of cooperation
among the North Carolina Medical Board, the
North Carolina Area Health Education Centers
(AHEC) Program, and the Cecil G. Sheps
Center for Health Services Research at the
University of North Carolina at Chapel Hill.
The North Carolina Medical Board has shared
descriptive information contributed by licensed
physicians as part of the annual registra-tion
process with the Sheps Center since
1976. The Center has published an
annual report and has conducted numer-ous
analyses for policy makers and pro-fessional
associations using these data.
The data used to produce this report are
the property of the North Carolina
Medical Board and are released only with
permission of the Board or its executive
director.
North Carolina Physicians’ Age
and Sex Distribution
In 1979, women made up 5.8% of
North Carolina’s active physician work
force [Figure 1]. Over one quarter
(27.4%) of the state’s physicians were 55
years of age or older, and 16.2% were
under 35 years old.
By 1988, the physician work force had
become dramatically younger [Figure 2]. This
was due to large increases in younger physi-cians
rather than loss of older doctors, as the
total number of physicians 55 or over had
increased. The proportion of physicians in the
35 to 54 range had not changed much from
1979 (56.5% to 55.1%), but the percentage of
physicians 55 and over had declined to 22.1%,
while the proportion of physicians under 35
had risen over 40% to 22.8%. The proportion
of female physicians in the state had more than
doubled to 12.5%, as nearly
one quarter (24.2%) of the
physicians under 35 years of
age were women.
The percentage of women
physicians practicing in the
state continued
to rise into
1998, when
more than one
in five physi-cians
(20.2%)
were women
[Figure 3].
The propor-tion
of female
physicians will
continue to
approach that
of males in the
future, as over
one third (36.4%) of the state’s
physicians under 35 years of
age were women, as were 39%
of the physicians younger than
30 years of age.
Nearly two thirds (64.7%)
of North Carolina’s physicians were between
the ages of 35 and 54 in 1998. The percentage
of physicians under 35 had declined to a 20-
year low of 15.6%, after a peak of 24.2% in
1983. There were fewer older physicians in the
state’s work force as well, as fewer than one
fifth (19.7%) of North Carolina’s physicians
were 55 years of age or older, the lowest per-centage
in the last 20 years.
Physician Demographics in Rural
North Carolina
In 1979, rural North Carolina had a higher
proportion of older physicians than the state,
with over one third (33.4%) being 55 years of
age or older. Women physicians were also
scarcer in non-metropolitan areas of the state
(see note), accounting for less than one twenti-eth
(4.6%) of the total. By 1988, the percent-age
of physicians 55 years of age or older had
declined by 18% to 28.4%. A higher propor-tion
of rural physicians was 55 or older than in
urban areas of the state in 1998, with 22.3% of
rural physicians being 55 or older. However,
there were similar proportions of physicians
between 35 and 54 (63.0% rural vs 65.2%
urban) and physicians under 35 (14.7% rural
vs 15.6% urban) compared to the rest of the
state. The proportion of women physicians in
rural North Carolina had increased sharply to
17.1%, with women accounting for 34.0% of
rural physicians under 35 years of age.
Although this is still a slightly lower proportion
than for the state, it represents a greater pro-portional
rate of increase in the period from
1988 to 1998 (67.1% to 61.7%).
Conclusions
The supply of physicians in North
Carolina is not subject to substantial
changes due to retirement or death. In
1998, the proportion of the state’s physi-cian
work force between the ages of 35
and 54 was the highest it had been in 20
years. This indicates that the supply will
remain stable over the near term. The
number of licensed, active physicians
who are women has grown rapidly since
1978; however, it will take many years
for the number of male and female physi-cians
to near equality.
————————————
Note
To consistently compare the urban-rural
distribution of physicians across 20 years, the
1993 OMB metropolitan definitions were used
for all the years studied.
Sources
North Carolina Health Professions Data Book, Cecil
G. Sheps Center for Health Services Research,
1979,1988,1998. u
PA/NP R
14 NCMB Forum
Effective May 1, 1999, the North Carolina Medical Board made
several changes to the physician assistant (PA) and nurse practitioner
(NP) rules. Our focus here will be on changes to the prescribing
authority of PAs and NPs. Requirements retained from the old rules
are restated; changes are highlighted in bold type. Rule references
are to the new rules.
Physician Assistants
PA Rules (21 NC Administrative Code Chapter 32, Subchapter S)
Documentation Requirements:
l Every PA must maintain at all approved practice sites written pre-scribing
instructions, signed by the PA and the supervising physi-cian(
s) (“SP”), which contain specific instructions from the SP to
the PA regarding prescribing, ordering, and administering drugs
and medical devices, and a policy for periodic review by the SP
of the PA’s prescribing, ordering, and administering drugs and
medical devices. [PA Rule .0109(2)] In addition, the new
rules state the PA and SP must acknowledge that each is
familiar with the laws and rules regarding prescribing and
agree to comply with these laws and rules by incorporating
them into the written prescribing instructions. [PA Rule
.0109(1)]
l Each prescription must be documented in the patient’s record
and include medication name and dosage, amount prescribed,
directions for use, number of refills, signature of the PA, and
cosignature by the SP within the time limits set forth in PA Rule
.0110(c). [PA Rule .0109(6)]
Prescribing Controlled Substances:
l In order to prescribe controlled substances, both the PA and the
SP must have a valid DEA registration. [PA Rule .0109(4)]
l In order to prescribe controlled substances, the old rule required
the PA and SP to sign a statement that they had read and under-stood
“the DEA MID-LEVEL PRACTITIONERS MANUAL
and the information sheet provided by the Board.” The new
rules do not mention this manual but, instead, state the PA
and SP “shall prescribe in accordance with information pro-vided
by the Medical Board and the DEA.” [PA Rule
.0109(4)]
l The old PA rule limited prescriptions for substances falling with-in
the categories 2, 2N, 3, and 3N to a legitimate seven day sup-ply.
The new PA rule states prescriptions for substances
falling within these categories “shall not exceed a legitimate
30 day supply.” [PA Rule .0109(4)]
NOTE REGARDING PRESCRIBING OF SCHEDULES 2, 2N,
3, AND 3N CONTROLLED SUBSTANCES: The PA rules do
not prohibit a PA from prescribing refills of category 2 and 2N
substances but current DEA regulations do not permit this. A
PA may write refills for 3 and 3N controlled substances but, as
stated above, the total amount prescribed, including refills, may
not exceed a legitimate 30 day supply.
Prescription Forms:
l Each prescription issued by a PA shall contain the PA’s name,
practice address, and telephone number; the PA’s license number
and, if controlled substances are prescribed, the PA’s DEA regis-tration
number; and the SP’s name and telephone number. [PA
Rule .0109(5)]
Professional Medication Samples:
l PAs who request, receive, and dispense to patients professional
medication samples must comply with all applicable state and
Recent Changes to PA and NP Prescribing Rules
R. David Henderson, JD
NCMB Legal Department
federal regulations. [PA Rule .0109(7)]
Compounding and Dispensing Drugs:
l In order to compound and dispense drugs, PAs must obtain
approval from the North Carolina Board of Pharmacy and follow
all Board of Pharmacy rules and federal guidelines. [PA Rule
.0109(3)]
Procuring Drugs:
l Language added at the beginning of PA Rule .0109 now per-mits
PAs to procure and dispense drugs and medical devices.
This is in addition to permission granted in theold rules to
“prescribe, order, and administer.”
Nurse Practitioners
NP Rules (21 N.C. Administrative Code Chapter 32, Subchapter M)
Documentation Requirements:
l Every NP must maintain at all practice sites written protocols
(formerly known as written standing protocols), signed by the
NP and the SP, which specify, among other things, the drugs and
devices that may be prescribed, ordered, and implemented by the
NP. [NP Rules .0109(b)(3) and .0108(b)(1)]
l Each prescription shall be noted on the patient’s chart and
include medication and dosage, amount prescribed, directions
for use, number of refills, and signature of the NP. [NP Rule
.0108(b)(5)]
Controlled Substances:
l An NP may prescribe or order controlled substances so long as
he/she has a valid DEA registration number which is entered on
each prescription for controlled substances. [NP Rule
.0108(b)(2)(A)] The new rules also allow an NP to procure
controlled substances so long as he/she has a valid DEA reg-istration
number. [NP Rule .0108(b)(2)]
l With a few exceptions, the old NP rules limited prescriptions for
substances falling within categories 2, 2N, 3, and 3N to a seven
day supply. The new NP rule states prescriptions for sub-stances
falling within these categories “are limited to a 30
day supply.” [NP Rule .0108(b)(2)(B)] Prescriptions for
these schedules may not be refilled. [NP Rule .0108(b)(2)(C)]
However, since current DEA regulations do not permit refills of
category 2 and 2N substances, this restriction applies, in effect,
only to category 3 and 3N substances.
Other Prescribing Requirements:
l NPs may prescribe a drug not listed in the written protocols only
if (1) there is a specific written or verbal order from the SP before
the prescription or order is issued by the NP, and (2) said writ-ten
or verbal order is entered in the patient record with a nota-tion
that it is issued on the specific order of the SP and the nota-tion
is signed by the NP and SP. [NP Rule .0108(b)(3)] See also
NP Rule .0101(11) (“ . . . Clinical practice issues that are not
covered by the written protocols require nurse practition-er/
physician consultation, and documentation related to the
treatment plan.”)
l Refills may be issued for a period not to exceed one year; how-ever,
as noted above, schedules 2, 2N, 3, and 3N may not be
refilled. [NP Rule .0108(b)(4)]
Prescription Forms:
l All prescriptions issued by an NP shall contain the SP’s name, the
name of the patient, and the NP’s name, telephone number, and
prescribing number assigned by the Medical Board. In addition,
continued on page 15
No. 3 1999 15
if a controlled substance is prescribed,
the prescription shall contain the NP’s
DEA registration number. [NP Rules
.0108(b)(6) and (7)]
Dispensing Drugs:
l An NP may obtain approval to dispense
the drugs and devices specified in the
written protocols from the North
Carolina Board of Pharmacy and must
dispense in accordance with all Board of
Pharmacy rules. [NP Rule .0108(c)]
Summary
Most of the language from the old PA and
NP prescribing rules remains in effect.
However, the new PA rules require the PA
and SP to acknowledge that each is familiar
with the laws and rules regarding prescribing
and agree to comply with these laws and
rules by incorporating them into the written
prescribing instructions. While PAs are no
longer required to read the DEA Mid-Level
Practitioners Manual, they are required to
prescribe in accordance with information
provided by the Medical Board and the
DEA. PAs may now prescribe categories 2,
2N, 3, and 3N substances in an amount not
to exceed a legitimate 30 day supply. Due to
DEA regulations, prescriptions for cate-gories
2 and 2N may not be refilled.
Prescriptions for categories 3 and 3N may be
refilled so long as the total amount pre-scribed
does not exceed a legitimate 30 day
supply. Finally, PAs may now procure and
dispense drugs and medical devices.
The new NP rules also permit NPs to pre-scribe
a 30 day supply of substances falling
within categories 2, 2N, 3, and 3N; howev-er,
as before with the old rules, refills are
expressly prohibited. Under the new rules,
NPs are now permitted to procure con-trolled
substances, in addition to prescribe
and order, so long as the NP has a valid DEA
registration and this is permitted by the writ-ten
protocols. Finally, if an NP prescribes a
drug not listed in the written protocols, the
new rules require the SP to co-sign the NP’s
notation of this prescription in the patient
record.
Copies of the PA and NP rules
may be ordered by leaving a message at
1-800-253-9653, ext. 269 (NC & VA) or
1-919-326-1109, ext. 269. Also, these
rules can be found on our Web site at
www.docboard.org/nc. Click on Rules in the
directory. The PA prescribing rules begin at
page 53 and the NP prescribing rules begin
at page 42. u
Recent Changes to PA/NP
Prescribing Rules
continued from page 14
REVIEW
The challenge usually comes in two
forms:
l “Doctor, please stop it. We all have to die.
This is futile.”
l “Care at the end of life is one of the biggest
costs in medicine. You doctors will just have
to learn to avoid that expense. It’s futile.”
Both statements are true. Neither is usu-ally
very useful. Who among us has not
wrestled with these thoughts at the bedside
of the elderly patient on dialysis? Who has
not grappled with the decision to open the
chest of a boy in cardiac arrest who is lifeless,
shot 20 minutes earlier through the chest?
The decision when to stop treatment or
progress from therapy to palliation remains
one of medicine’s great challenges, especially
in this decade of increasing technology, mea-sures
that now enable life in situations previ-ously
regarded as hopeless. Accordingly, I
was delighted to run across When Doctors Say
No: The Battleground of Medical Futility by
Susan B. Rubin, a “philosopher and bioethi-cist,
a co-founder of The Ethics Practice, a
California firm devoted to providing
bioethics education, research, and clinical
consultation.” Ahh, here is an expert who
may illuminate this dark tunnel of our prac-tice.
What a disappointment. She not only
fails to address the two real challenges noted
in my first paragraph, she replaces these with
a flimsy third thesis. She claims that physi-cians
make decisions about medical futility
on their own without consulting others. She
rejects “the popular arguments supporting
unilateral decision making by physicians and
calls instead for a different kind of conversa-tion
about the central values at stake when
doctors and patients so dramatically dis-agree.”
Dr Pories
When Is It Futile?
Walter J. Pories, MD
Member, NCMB
Dr Rubin, you need to get out more. In
my many years of practice in a variety of set-tings,
ranging from trauma centers to small
hospitals, as well as military hospitals during
our wars, I rarely found a physician making
a unilateral decision regarding the futility of
treatment. In contrast, I encountered just
the opposite. Physicians invariably seek help
and advice from families, friends, colleagues,
nurses, social workers, ministers, and ethi-cists
before cessation of treatment. Further,
“dramatic disagreements” between doctors
and patients are also a rare occurrence. No,
instead we often sit long hours with patients
and their families, pondering the future and
how to address it with kindness, control of
pain, husbandry of resources, and affection.
Even at the end of the drama of failed car-diac
arrest, the senior physician will always
ask, “I think it’s time. Agree?” Deciding
when someone is to die is too heavy a deci-sion
for us, as physicians, to make alone. In
contrast to Dr Rubin’s contention, we do
not reject advice, we seek it.
___________________________
When Doctors Say No: The Battleground of
Medical Futility
Susan B. Rubin
(in the Medical Ethics Series, edited by
Smith and Veatch)
Indiana University Press, Bloomington and
Indianapolis, 1998
191 pages (notes, bibliography, index),
$24.95 cloth
(ISBN 0-253-33463-2)
___________________________
Unfortunately, Dr Rubin concentrates on
a non-issue and misses the big one: how do
we know when our therapies will be futile?
I have seen a young Air Force sergeant
recover apparently full faculties after two
years of coma. When I ran the Hospice in
Cleveland, Ohio, we were sent a moribund
woman with massive metastatic breast can-cer,
clearly ready to die, who, after we treat-ed
her with hydration, hormones, and
chemotherapy, lived another five years, long
enough to watch her children graduate from
high school. On the other side of the coin,
I have also despaired at the costs, both fiscal
and emotional, incurred by the septic patient
with necrotizing fasciitis who finally died
after a number of operations and months in
continued on page 16
Logo behind text
16 NCMB Forum
When is it Futile?
continued from page 15
continued on page 17
the intensive care unit.
Dr Rubin’s failure to focus may be due to
her turgid writing: “My conceptual analysis
of futility will treat each epistemological
question separately.” Or how about this sen-tence?
Though the leaky bucket metaphor
and its underlying presumptions
have been used, perhaps unwit-tingly,
to support normative argu-ments
in favor of physician author-ity
to refuse unilaterally to provide
treatment on the grounds of futili-ty,
neither the metaphor nor its
underlying presumptions are prob-lem
free.
That’s tough reading, and not worth the
time. Too bad, too; the challenge of “futili-ty”
deserves far more emphasis. As a society,
we need to address this issue. Do we follow
the lead of our British colleagues who ration
by resources, the Colorado Medicaid format
that limits by a list of therapies, or do we
continue to muddle on with continuing
arguments about cost while ignoring com-passion?
Where are the data to help us make
these decisions?
We are still waiting for the book that will
help us with these decisions. So far, the
Bible and the Koran still seem to be the best
authorities. Let me recommend that you
continue to read these two references until
something better than Dr Rubin’s book
comes along. u
LETTER TO THE EDITOR
Two Questions:
Romantic Relationships,
Splitting Fees
To the Editor: Ever since I read a scenario in
the Forum, I have wondered whether there
was more to the story than was written
because it raised questions about what I
think may be a common circumstance, espe-cially
in smaller towns. The item appeared
sometime in the past year or so. [Forum #4,
1997, page 24.]
As I recall, the case concerned a male MD
in a multi-physician group who gave a phys-ical
to one of the female employees who did
not work directly for or with him. Some
time after this, they started dating and hav-ing
a sexual relationship. The Forum indi-cated
that the man’s license was suspended,
placed on probation, or canceled—I can’t
recall which, but any of the three sounded
awfully severe. (And who filed the com-plaint
that brought it to the Board’s atten-tion
anyway? The employee? Another, per-haps
jealous, employee or patient? Or some
anonymous observer? Does that make a dif-ference?
Who or what determines “no
harm, no foul”?) Would it have made a dif-ference
if the employee worked directly for
or with the doctor, was paid by him?
I understand that “consensual,” in some
instances (eg, professor and student, CEO
and middle manager), may raise questions,
per se, of propriety/ethics, but where is the
line drawn? A patient who happens to be
the mayor is inherently in a position that
may make the doctor actually the one who
could be “beholden.” (An “inherently
unequal” relationship actually is the norm
for almost any relationship, if you choose to
see it that way.) “The very appearance of
impropriety is enough to assume impropri-ety”?
If so, “impropriety” in whose eyes?
Also, eg, how many wives work in their hus-bands’
offices, whether in a clinical or a non-clinical
capacity? (And does the latter dis-tinction
make any difference?) If that is all
right, what if they were just engaged or just
dating? At what point is it questioned by
the Board?
Does someone have to file a complaint?
And does that someone have to be verified
as not having his or her own ax to grind in
the situation?
So, my question concerns to what length
the North Carolina Medical Board takes this.
For example, if I, as a specialist, am asked to
see a patient in consultation for a brief peri-od
of time, does that mean that if I am asked
out to dinner by that (former) patient five
years later I am unethical if I accept and
could have my license yanked and black
marks on my record forever? Or, if I am
already friends with that person from church
or school or if I am already dating that per-son,
if they come to me because they already
know me, and we continue or start to date,
is that relationship with the patient unethical
in the Board’s eyes? And what does the
parameter of during or after—and how long
after—the limited doctor-patient interaction
matter? What if it is an ongoing but inter-mittent
relationship, such as sewing a lacera-tion
or freezing a wart? If there is any mid-dle
ground, does it revolve around whether
or not there is a sexual component? If so,
how sexual? What makes a difference to the
Board: a good-night kiss, a thank-you hug,
an arm around the shoulder, holding hands,
or a Clintonesque contact?
It seems there’s an awfully slippery slope
here. Especially in a small town there may
be “slim pickins” for a single doctor who is
still interested in having relationships, and
the odds are high that some of the scenarios
I’ve suggested could obtain.
Perhaps I misread the original article, but
I believe you can tell where I would like
some clarification.
Also, in that same issue [#4, 1997, page
13], there was a reference to not being
allowed to split profits with other health care
workers, except as allowed under a specific
statute, which was not explained. Could you
explain that statute? And does this mean
that if a more experienced associate (but not
legal partner) of mine or even someone in
another practice helps me on a complicated
procedure that I am not allowed to say thank
you in a monetary way? (Say a procedure
not allowed to be coded for an assistant’s
fee.)
Thanks in advance for responding to my
concerns.
A North Carolina Physician
Response
Volumes have been written on your first ques-tion
and I’ll not try to reproduce them here.
Your description might apply to several recent
cases, so I’ll also not try to elaborate on any par-ticular
case. There would be further public
record beyond what was in the Forum, but the
Forum is usually a close paraphrase of the legal
documents in the public record.
Informative Video Tapes
The Magic Kiss: Sexual Misconduct and
Boundary Violations [114 minutes; 1997]
A seminar conducted at the offices of the NCMB
by Barbara S. Schneidman, MD, MPH, then
Associate Vice President of the American Board of
Medical Specialties and now Director of the AMA
Office of Medical Education Liaison and
Outreach. This is the presentation Dr
Schneidman has made before a number of state
medical boards and other medical groups over the
past several years. Available from the NCMB’s
Public Affairs Office for $10.00 (which
includes mailing charge). (Please inquire for
costs if requesting shipping outside the U.S.)
Edmund D. Pellegrino: “Why Do We
Speak of Responsibility?” [25 minutes;
1994]
Distinguished medical ethicist discusses the duties
of medical board members, the ethics of medical
practice, and the role of medical educators. Dr
Pellegrino is Director of the Center for Clinical
Bioethics at Georgetown University Medical
Center. Available from the NCMB’s Public
Affairs Office for $12.95 (which includes mail-ing
charge). (Please inquire for costs if
requesting shipping outside the U.S.) u
No. 3 1999 17
Letter to the Editor
continued from page 16
North Carolina Medical Board
Meeting Calendar, Application Deadlines, Examinations
November 1999 -- September 2000
Board Meetings are open to the public, though some portions are closed under state law.
North Carolina Medical Board November 17-20, 1999
November Meeting Deadlines:
Nurse Practitioner Approval Applications October 4, 1999
Physician Assistant Applications October 6, 1999
Physician Licensure Applications November 2, 1999
North Carolina Medical Board January 19-22, 2000
January Meeting Deadlines:
Nurse Practitioner Approval Applications December 6, 1999
Physician Assistant Applications November 24, 1999
Physician Licensure Applications January 4, 2000
North Carolina Medical Board March 15-18, 2000
March Meeting Deadlines:
Nurse Practitioner Approval Applications January 31, 2000
Physician Assistant Applications January 28, 2000
Physician Licensure Applications February 29, 2000
North Carolina Medical Board May 24-27, 2000
May Meeting Deadlines:
Nurse Practitioner Approval Applications April 10, 2000
Physician Assistant Applications March 24, 2000
Physician Licensure Applications May 9, 2000
North Carolina Medical Board July 19-22, 2000
July Meeting Deadlines:
Nurse Practitioner Approval Applications June 5, 2000
Physician Assistant Applications July 5, 2000
Physician Licensure Applications July 3, 2000
North Carolina Medical Board September 20-23, 2000
September Meeting Deadlines:
Nurse Practitioner Approval Applications August 7, 2000
Physician Assistant Applications September 5, 2000
Physician Licensure Applications September 5, 2000
Residents Please Note USMLE Information
United States Medical Licensing
Examination Information
(USMLE Step 3)
The May 1999 administration of the USMLE Step 3 was the last
pencil and paper administration. Computer-based testing for Step 3
is expected to be available on a daily basis in November 1999.
Applications may be obtained from the office of the North Carolina
Medical Board by telephoning (919) 326-1100. Details on administra-tion
of the examination will be included in the application packet.
Special Purpose Examination (SPEX)
The Special Purpose Examination (or SPEX) of the Federation of
State Medical Boards of the United States is available year-round.
For additional information, contact the Federation of State Medical
Boards at 400 Fuller Wiser Road, Suite 300, Euless, TX 76039 or
telephone (817) 868-4000.
*
Each case is decided on its own facts.
Generally, in “boundary violation” cases, as we
generically refer to them, we are looking for an
abuse of the power differential inherent in the
physician/patient relationship, just as you sug-gest.
Abuses of the power differential in the
employment relationship, coupled with dissolved
or dissolving boundaries in the physician/patient
relationship, might be worrisome in themselves
or suggestive of worse things to come. Treating
anyone with whom the physician has a
personal or other relationship (beyond the physi-cian/
patient relationship) could also be consid-ered
a boundary violation, though perhaps a less
severe one. It also frequently leads to care pro-vided
to a lower standard than that provided
those who are simply patients.
The Board gets its information from a variety
of sources. For the Board to have acted, either
the physician must have admitted the conduct in
the accusation or the Board must have proven it.
An unverified complaint from someone with an
ax to grind might get an investigation started,
but it usually won’t win at trial.
Exploitation of the power differential being
the issue, the more recent and extensive the con-tact
between patient and physician, the more
likely the Board is to see a problem. Standards
certainly were different in the past when many
communities had only one physician and when
physicians generally did not go outside their
communities for dates or anything else. In 1999
North Carolina, the Board might doubt your
“small town defense.”
Your reference to the statutory “exception” to
the prohibition against fee splitting is probably
NC Gen Stat 55B-14(c), the one allowing
physicians and certain others to own shares
together in a single professional corporation (eg,
psychiatrists and psychologists; ophthalmologists
and optometrists).
Thanks for reading the Forum.
James A. Wilson
Director
NCMB Legal Department u
Audio Tape: “End-of-
Life Decisions Forum”
End-of-Life Decisions Forum [4 hours;
1998]
Transcription of a conference developed and pre-sented
by the staffs of the North Carolina Medical
Board, the North Carolina Board of Nursing, and
the North Carolina Board of Pharmacy. Held in
Raleigh, North Carolina, on October 23, 1998,
the conference was designed to provide a forum
for health care regulators, professionals, and poli-cy
makers to explore the ethical, legal, and other
issues surrounding end-of-life decisions and to ini-tiate
a continuing process for addressing such
issues. Speakers included Lawrence O. Gostin,
JD, LLD (Hon), Co-Director of the Johns
Hopkins University and Georgetown University
Program on Law and Public Health; George C.
Barrett, MD, Vice President of the Federation of
State Medical Boards and past president of the
North Carolina Medical Board; Anne Dellinger,
JD, Professor of Public Law and Government at
the University of North Carolina; Bill Campbell,
PhD, Dean of the University of North Carolina
School of Pharmacy; David A. Swankin, JD,
President of the Citizen Advocacy Center; Nancy
M.P. King, JD, Associate Professor of Social
Medicine at the University of North Carolina;
Sharon Dixon, RN, MPH, Senior Vice President
of Clinical Services at the Hospice of Charlotte;
Joseph A. Buckwalter, MD, President of the
North Carolina Hemlock Society; Cathy Clabby,
MA, Medical Reporter for the Raleigh News and
Observer; and the executive directors of the three
host boards. On two 120 - minute audio cas-settes.
Available from the NCMB’s Public
Affairs Office for $10.00 (which includes mail-ing
charge). (Please inquire for costs if
requesting shipping outside the U.S.) u
18 NCMB Forum
ANNULMENTS
NONE
REVOCATIONS
NONE
SUSPENSIONS
TRITES, Paul Nathan, MD
Location: Richfield, MN
DOB: 8/13/1953
License #: 0000-27326
Specialty: OPH/IM (as reported by physician)
Medical Ed: University of Minnesota (1980)
Cause: A hearing before the Board on 5/20/1999 on charges dated
10/06/1998. Dr Trites was disciplined by the Minnesota Board
of Medical Practice on or about 1/10/1998 for failure to record
adequate information in the medical records of three patients,
failure to promptly provide medical records to two patients, and
failure to cooperate with the Minnesota Board’s investigation of
his practice. In testimony before the North Carolina Medical
Board, he continued to blame former staff members and attor-neys
for the problems cited. He presented a copy of an Order of
Unconditional License dated 3/13/1999 in which the Minnesota
Board conferred on him an unconditional license to practice;
however, he did not prove to the North Carolina Board that he
has corrected the underlying problems that led to the discipline
imposed by Minnesota.
Action: 6/10/1999. Findings of Fact, Conclusions of Law, and Order of
Discipline issued: Dr Trites’ North Carolina medical license is
suspended indefinitely.
See Consent Orders:
CLARK, Richard Stroebe, MD
NOONAN, Kevin Bernard, MD
WESSEL, Richard Fredrick, Jr, MD
SUMMARY SUSPENSIONS
DIAMOND, Patrick Francis, MD
Location: Evergreen, NC (Columbus Co)
DOB: 5/15/1946
License #: 0098-00042
Specialty: FP (as reported by physician)
Medical Ed: Universidad Autonoma de Tamaulipas, Mexico (1987)
Cause: Upon information that Dr Diamond may be unable to practice
medicine with reasonable skill and safety by reason of illness,
drunkenness, excessive use of alcohol, drugs, chemicals, or any
other type of material or by reason of a physical or mental abnor-mality.
Action: 6/28/1999. Order of Summary Suspension of License issued,
effective 7/01/1999. [Notice of Charges issued 6/28/1999.]
CONSENT ORDERS
AQUILINA, Joseph Nicholas, MD
Location: Saginaw, MI
DOB: 3/07/1935
License #: 0000-38581
Specialty: U (as reported by physician)
Medical Ed: University of Munich, West Germany (1962)
Cause: Dr Aquilina admits and the Board finds that by an order of
11/17/1998, the Wyoming Board of Medicine restricted Dr
Aquilina’s license based on false answers submitted by him on
his license renewal applications in 1997 and 1998.
Action: 5/26/1999. Consent Order executed: Dr Aquilina shall not
practice medicine in North Carolina unless and until the follow-ing
requirements are met and the Board issues an order permit-ting
such practice: should he desire to practice in North
Carolina, he shall first notify the Board and he shall then be
interviewed to determine if he can practice safely and skillfully
and if he possesses the character and integrity expected of North
Carolina physicians; must comply with other conditions.
BORISON, Richard Lewis, MD
Location: Augusta, GA
DOB: 3/04/1950
License #: 0096-00068
Specialty: P/PYG (as reported by physician)
Medical Ed: University of Illinois (1977)
Cause: Dr Borison has been disciplined by the Georgia medical board
and surrendered his Georgia license in October 1998; he execut-ed
a plea agreement, which was accepted by the Superior Court
of Richmond County, Georgia, in October 1998 in which he
admitted he was guilty of one RICO count, 18 counts of Theft
by Taking, 10 counts of Theft of Services, and 7 counts of False
Statements and Representations.
Action: 7/24/1999. Consent Order executed: Dr Borison surrenders his
North Carolina license immediately.
BOSHOLM, Carol Christine, MD
Location: Hendersonville, NC (Henderson Co)
DOB: 10/10/1953
License #: 0096-00151
Specialty: IM (as reported by physician)
Medical Ed: University of Medicine and Dentistry of New Jersey (1989)
Cause: On information that Dr Bosholm has been disciplined by the
New York State Board for Professional Medical Conduct. The
Board finds and she admits that by an Order dated 12/05/1997
New York placed her license on probation for five years based on
false answers submitted by her on her New York license applica-tion.
Action: 6/25/1999. Consent Order executed: the Board reprimands Dr
Bosholm.
Annulment:
Retrospective and prospective cancellation of the
authorization to practice.
Conditions:
A term used for this report to indicate restrictions
or requirements placed on the licensee/license.
Consent Order:
An order of the Board and an agreement between
the Board and the practitioner regarding the
annulment, revocation, or suspension of the
authorization to practice or the conditions and/or
limitations placed on the authorization to practice.
(A method for resolving disputes through infor-mal
procedures.)
Denial:
Final decision denying an application for practice
authorization or a motion/request for reconsider-ation/
modification of a previous Board action.
NA:
Information not available.
NCPHP:
North Carolina Physicians Health Program
RTL:
Resident Training License.
Revocation:
Cancellation of the authorization to practice.
Summary Suspension:
Immediate temporary withdrawal of the autho-rization
to practice pending prompt commence-ment
and determination of further proceedings.
(Ordered when the Board finds the public health,
safety, or welfare requires emergency action.)
Suspension:
Temporary withdrawal of the authorization to
practice.
Temporary/Dated License:
License to practice medicine for a specific period
of time. Often accompanied by conditions con-tained
in a Consent Order. May be issued as an
element of a Board or Consent Order or subse-quent
to the expiration of a previously issued tem-porary
license.
Voluntary Dismissal:
Board action dismissing a contested case.
Voluntary Surrender:
The practitioner’s relinquishing of the authoriza-tion
to practice pending an investigation or in lieu
of disciplinary action.
NORTH CAROLINA MEDICAL BOARD
Board Orders/Consent Orders/Other Board Actions
May, June, July 1999
DEFINITIONS
BROOKS, Michael Lee, MD
Location: Pembroke, NC (Robeson Co)
DOB: 11/24/1950
License #: 0000-28845
Specialty: IM/EM (as reported by physician)
Medical Ed: Bowman Gray School of Medicine (1979)
Cause: From March to May 1998, DAC Health, Inc, acting through Dr
Brooks and various PAs in its employ, rendered medical care to
patients in Raeford, NC, although, under the “corporate practice
doctrine,” a business corporation generally may not practice
medicine. Thus, it engaged in the unauthorized practice of med-icine.
Dr Brooks assisted in this unauthorized practice, permit-ting
DAC Health to bill patients and third-party payors and to
collect payments for all medical services rendered by him; from
these fees, DAC Health paid Dr Brooks salary and kept the
remainder to pay expenses and as profit; by splitting fees with
DAC Health, Dr Brooks engaged in unprofessional conduct. On
March 9, 1998, Robert M. Chavis, PA, began practicing at DAC
Health under Dr Brooks supervision even though the Board did
not approve Mr Chavis’ notification of intent to practice until
March 19; Dr Brooks should have verified Mr Chavis’ status and
should not have supervised a PA who was not approved; in doing
this, Dr Brooks assisted in the unauthorized practice of medicine.
While employed by DAC Health, Dr Brooks dispensed prescrip-tion
drugs for a fee to his patients even though he was not reg-istered
with the Pharmacy Board, thus violating a law involving
the practice of medicine. Dr Brooks failed to countersign 7
charts of patients seen by Mr Chavis within the time required by
rule; he did countersign charts for 2 patients seen at DAC Health
before he came to there and with whose care he had nothing to
do. He states he was unaware his working at DAC Health was
improper and that he quit working for DAC Health when he
became aware of certain problems. He has been cooperative and
has acknowledged his wrongdoing.
Action: 7/22/1999. Consent Order executed: Dr Brooks is reprimand-ed.
CHEN, Jackson Wushoung, MD
Location: Oak Brook, IL
DOB: 11/13/1941
License #: 0000-18357
Specialty: PD/FP (as reported by physician)
Medical Ed: National Taiwan University, ROC (1966)
Cause: Dr Chen executed a Consent Order with the Illinois Department
of Professional Regulation on 4/2/1998 under which he was rep-rimanded
and his license subjected to various probationary
terms. [A copy of the Illinois Consent Order is attached to this
Consent Order and says, among other things, that information
had come to the attention of the Department that he provided
medical services to an entity which was precluded from engaging
in treatment of patients pursuant to Illinois law and that he
allegedly failed to follow proper protocols with regard to hospi-tal
admission of patients, procedures relating to dispensing of
controlled substances and communication with other physicians
involved in patient care. Dr Chen denied the allegations but
accepted the terms and conditions of the Consent Order.
Among other things, his license was placed on probation for one
year and he was fined $10,000.00; his Illinois controlled sub-stance
license was suspended for a period of 90 days.]
Action: 7/8/1999. Consent Order executed: The Board reprimands Dr
Chen; he shall comply in all respects with the Illinois Consent
Order; each calendar year, beginning with 1999, Dr Chen shall
obtain and document to the Board 50 hours of practice-relevant
Category I CME; must comply with other terms and conditions.
CLARK, Richard Stroebe, MD
Location: Memphis, TN
DOB: 10/27/1938
License #: 0000-32670
Specialty: GS/NTR (as reported by physician)
Medical Ed: University of Southern California, Los Angeles (1959)
Cause: Dr Clark admits and the Board finds that he was disciplined by
the Arkansas State Medical Board on 7/18/1998 for pre-signing
blank prescriptions in violation of state and federal laws and that
his Arkansas license was suspended from 6/04/98 to 9/01/1998.
Action: 5/19/1999. Consent Order executed: Dr Clark’s North Carolina
medical license is suspended retroactively from 6/04/1998 to
9/01/1998; to the extent he has not already done so, he shall
comply with the terms of the Order entered by the Arkansas
Board on 7/18/1998 and as that Order may be amended; in
1999, he shall obtain 50 hours of practice-relevant Category I
CME, at least 25 hours of which must be in a public forum; must
comply with other conditions.
CROLAND, David Alan, DO
Location: Little River, SC
DOB: 11/27/1962
License #: 0097-01729
Specialty: FP (as reported by physician)
Medical Ed: Southeastern College of Osteopathic Medicine (1989)
Cause: To amend an existing Consent Order. Dr Croland entered a
Consent Order with the South Carolina board in which he
admitted, among other things, that he furnished fraudulent
information in orders and documents purporting to be prescrip-tions,
which were issued outside the reasonable bounds of a prac-titioner-
patient relationship and for other than legitimate med-ical
purposes, that he furnished fraudulent documents to obtain
and supply his office with fentanyl and other controlled sub-stances
for administration to himself, and that he furnished false
and fraudulent material information to his medical records that
indicated he administered fentanyl and other controlled sub-stances
to patients when he had in fact used them himself; he
later applied for a license in North Carolina and was issued a
license pursuant to a Consent Order on 12/08/1997. He has
asked that his Consent Order be amended so he can prescribe
Schedule IIN controlled substances. It appears his recovery is
going well and he has complied with the terms of his Consent
Order.
Action: 5/11/1999. Consent Order executed: Dr Croland is issued a
license to practice medicine; he shall maintain and abide by a
contract with NCPHP; unless lawfully prescribed for him by
someone else, he shall not consume alcohol, controlled sub-stances,
or any other abusable substance; at the Board’s request,
he shall supply bodily fluids or tissue for screening to determine
if he has consumed alcohol, controlled substances, or any other
abusable substance; he shall not use, dispense, administer, pre-scribe,
or possess, in any manner, Schedule II controlled sub-stances,
Stadol, and Nubain, nor permit these drugs to be in his
office for any purpose; he shall obtain drug and alcohol counsel-ing
from a therapist approved in writing by the president of the
Board; he shall direct his therapist to send quarterly reports to
the Board; he shall attend NA meetings as directed by his thera-pist
and the NCPHP; must comply with other conditions; the
numbered sections of this Consent Order supersede those impos-ing
any continuing obligation in any prior consent order except
those regarding the public nature of such consent orders.
DUNN, Clarence Alvin, Jr, MD
Location: New York, NY
DOB: 12/05/1930
License #: 0000-13790
Specialty: ORS/OTR (as reported by physician)
Medical Ed: University of North Carolina School of Medicine (1963)
Cause: On or about 2/09/1998, the New York Board issued a
Determination and Order by which Dr Dunn’s New York med-ical
license was revoked for misconduct related to practicing
medicine after he was aware his registration had lapsed, allowing
a certification that had been altered to accompany his application
for privileges on two occasions, and for willful failure to register.
Action: 6/29/1999. Consent Order executed: Dr Dunn surrenders his
North Carollina license and the Board accepts that surrender.
ENGLEMAN, James Donald, Jr, MD
Location: Vanceboro, NC (Craven Co)
Greenville, NC (Pitt Co)
DOB: 4/05/1960
License #: 0000-32696
Specialty: FP (as reported by physician)
Medical Ed: University of Louisville (1985)
Cause: To amend an existing Consent Order. Dr Engleman surrendered
his license in June 1995 after relapsing in his use of opiates; on
October 12, 1998, he was issued a temporary license pursuant
to a Consent Order of October 8, 1998; his current Consent
Order says he may not work more than 30 hours a week and Dr
Engleman has asked that limit be removed; the Board has agreed
to his request.
Action: 5/07/1999. Consent Order executed: Dr Engleman is issued a
license to expire on the date shown on the license; he shall prac-tice
only in a setting first approved by the Board’s president; he
shall arrange and pay for a physician monitor who shall be
approved by the Board’s president; the monitor shall regularly
review Dr Engleman’s practice and report to the Board quarter-ly;
unless lawfully prescribed for him by someone else, Dr
Engleman shall refrain from use of all mind and mood altering
substances and all controlled substances and from the use of alco-hol;
he shall notify the Board in writing within 2 weeks of any
No. 3 1999 19
such use, identifying the prescriber and the pharmacy filling the
prescription; at the request of the Board, he shall supply bodily
fluids or tissue for screening to determine if he has consumed any
of these substances; he shall maintain and abide by a contract
with NCPHP; he shall attend AA, NA, and/or Caduceus meet-ings
as recommended by NCPHP; he shall maintain a monthly
log of all controlled substances he prescribes, orders, or adminis-ters
and deliver a copy of that log to the Board each month; he
shall continue psychotherapy with his current therapist or such
other person as may be approved by the Board’s president; he
shall direct his therapist to provide quarterly reports of his
progress to the Board; he shall obtain 50 hours of Category I